On the Path to Health and Wellness: Southern Avalon Community Health Needs Assessment by Eastern Health

June 27, 2007 Ms. Joan Dawe: Chair, Board of Trustees Eastern Health Dear Ms. Dawe: I am pleased to submit On the Path to Health and Wellness: Southern Avalon Community Health Needs Assessment. This community health needs assessment is the second in a series of assessments carried out by Eastern Health (Navigating the Way Together: Burin Peninsula Community Health Needs Assessment was released in June 2006). These community health needs assessments contribute to meeting the goals of Eastern Health’s first strategic plan by addressing a strategic priority of the Board. They identify health-related trends within Eastern Health’s boundaries, and help the organization see the similarities and differences in needs that exist in the various parts of the region. This community health needs assessment provides the organization with an in-depth look at the issues faced by the communities and people of the Southern Avalon. It was conducted in the period September 2006-February 2007, using the same process as the Burin Peninsula Community Health Needs Assessment. In this approach, community health needs are viewed in the broadest sense by using the lens of the determinants of health. This method goes beyond focusing solely on the health services available in the region; it considers all those factors that impact on a person’s health and well-being. The findings of this community health needs assessment incorporate recommendations for action by Eastern Health. Several of these recommendations are also found in the Burin Peninsula report, suggesting that the issues driving these recommendations are significant in the Southern Avalon as well as for the Burin Peninsula. A condensed synopsis of the needs assessment is included with this report (Section 2: pages II-XI). It provides highlights from the needs assessment process, summarizes the key findings and recommendations, and describes the challenges facing the people and communities of the Southern Avalon based on anecdotes and comments heard from key informants and focus group participants. This synopsis is designed to be a readable and accessible stand-alone summary of the report. The detailed document provides supportive background information on the needs assessment process, the Southern Avalon region, and the specific findings and recommendations related to the determinants of health and Eastern Health’s lines of business. A Steering Committee of Eastern Health staff and an Advisory Committee of community members guided the needs assessment process and provided valuable input and analysis. The recommendations target the priority issues that were identified through the needs assessment and validated by these committees. We look forward to responding to the recommendations of the report in partnership with the people of the Southern Avalon. We commit to informing the people of the Southern Avalon region of our progress in implementing these recommendations.

George Tilley President and Chief Executive Officer

1. Acknowledgements Many people made contributions to this community health needs assessment. In particular, Eastern Health thanks the many residents of the Southern Avalon region who welcomed the needs assessment, took an active role in promoting it and participated by sharing their views. In addition, many Eastern Health staff provided information and expertise on many of the topics. In particular, we thank the following people for their contribution:

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Key informants, focus group and telephone survey participants

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Advisory Committee members: Dianne Costello, Rita Pennell, Tony Healey, Maxine Gregory, Sherry Walsh, Elaine Murray and Lorelei Roberts-Loder

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Steering Committee members: Wayne Miller (chair), Jane Macdonald (project coordination), Mary Rossiter George Andrews, Sandra Gear, Bertha Butler, Marian Mooney, Doris Lewis, Janice Dalton, Natalie Moody, Laura Woodford, Judy Power. (Chief Operating Officers Fay Matthews, Alice Kennedy and Beverley Clarke served as ex-officio members.)

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Diana Moores and Patricia Rideout (administrative support)

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Barbara Young, Roger Chafe and Tele-link Research Inc. (telephone survey)

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Priscilla Corcoran Mooney, Sandra Gear and Tracy Tizzard-Drover, (focus group recorders)

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Terry Hoban, P4 Youth Centre

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Ulricke Fisher, Paula Birmingham, Judy Lynn Wiseman, Susan Ryan (utilization information)

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Roy Dawe (infrastructure assessment)

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Don MacDonald and Tracy Chislett, Newfoundland Centre for Health Information

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Lisa Browne (review and feedback on drafts)

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Dr. Jane Green, Professor of Medical Genetics, Memorial University Faculty of Medicine

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Sean Kilpatrick, Program Policy Analyst, Newfoundland and Labrador Housing Corporation

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Angela Benmore-Lawrence, graphic design

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Laura Woodford, editing

2. Synopsis & Recommendations Background Eastern Health is the largest health services organization in the province of Newfoundland and Labrador and has both regional and provincial responsibilities. Eastern Health provides the full continuum of care and service including community services, long term care and acute care. As seen in the figure below, the Eastern Health region extends west from St. John’s to Port Blandford and includes all communities on the Avalon, Burin and Bonavista Peninsulas.

The Southern Avalon The Southern Avalon area (population 16,164 - 2006 Census1), outlined by a solid line on the map, is the second area within Eastern Health to participate in a community health needs assessment. (The Burin Peninsula was the first: Navigating the Way Together: Burin Peninsula Community Health Needs Assessment was released in June 2006). The Southern Avalon extends from Bay Bulls along the Southern Shore to Trepassey and St. Shott’s; along the east side of St. Mary’s Bay to the Salmonier area and Colinet; along the west side of St. Mary’s Bay to Branch and the Cape Shore to Placentia; and along the east side of Placentia Bay to Long Harbour-Mt. Arlington Heights. What is a Community Health Needs Assessment? A community health needs assessment gathers information about the health-related needs of a particular area from both a factual and an opinion perspective. The assessment identifies key themes, prioritizes needs, develops recommendations and lays out an action plan. In this way, information is translated into knowledge that can be used for action. Eastern Health believes: ◆ Communities have the strengths, knowledge and skills necessary to originate programs which influence the determinants of health and which promote overall health and well-being. ◆

Individuals have an important role to play in making communities a healthier place to live.2

How did Eastern Health conduct the Southern Avalon Community Health Needs Assessment? The Southern Avalon Community Health Needs Assessment plan followed the format used for the Burin Peninsula needs assessment in 2006 (Navigating the Way Together: Burin Peninsula Community Health Needs Assessment). Step One: Getting Started (developed a plan, struck Steering and Advisory Committees) Step Two: Identifying Health Priorities (collected and analysed data, confirmed key themes) Step Three: Assessing a Health Priority for Action (selected priorities, shared conclusions) Step Four: Planning for Change (developed recommendations and action plans) Step Five: Moving On/Review (ongoing reports to community, board)

The Determinants of Health The framework for this community health needs assessment is the determinants of health. These determinants have a major influence on the health of people and communities and their linkage is important to understand. In order to achieve Eastern Health’s vision of Healthy People, Healthy Communities, we need to understand the impact these determinants are having in the lives of people and communities. ◆

Income and Social Status

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Employment and Working Conditions

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Education

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Physical Environment

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Social Environments

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Personal Health Practices and Coping Skills

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Health Services

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Gender and Culture

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Biology and Genetic Endowment

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Social Support Networks

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Healthy Child Development

Our Findings The Strengths of the Southern Avalon People and Communities: ◆

People are resilient and determined

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Families are close-knit

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People care for their neighbours and support each other in difficult times

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People speak up for their region and want to be involved in finding solutions

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Communities are proud of their culture and history; they maintain a close sense of community

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Communities are beginning to work together on regional efforts

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Communities are developing some innovative strategies to cope with their challenges

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Communities closer to St. John’s are stable or growing in population

The Challenges Facing the Southern Avalon People and Communities: ◆

Lack of local employment options

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Low incomes

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Significant out-migration and decline in population

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Aging population and loss of social support networks

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Withdrawal of some public and private sector services

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Road conditions, distances to services and lack of transportation

During the Southern Avalon Community Health Needs Assessment, many conversations were held with key informants (45 interviews) and focus groups (17 focus groups) about the needs of the region. Some comments about the challenges being faced by youth, adults, and seniors in the region were heard repeatedly.

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The themes that emerged in the needs assessment are presented here as quotes from those who shared their insights about the region. Their comments provide a perspective on the challenges to living a healthy life on the Southern Avalon today. Youth ◆ The numbers of youth in the Southern Avalon have significantly decreased. “There are really not a lot of kids in this community. If my kids didn’t have each other, they wouldn’t have any playmates.” - Key Informant “We weren’t able to get a ball hockey league together this year. There aren’t ten males in this community between the ages of 17-35.” - Key Informant ◆

It’s challenging to keep organized activities for youth going, with small numbers of participants and fewer adults to act as volunteers. “It’s a struggle to keep the Girl Guides going. We have so few kids here now and few volunteers.” Focus Group Participant “There are not a lot of outlets for kids around here. A small number of kids participate in sports, but not everyone likes that.” - Key Informant “No where to go and nothing to do - so kids are experimenting with drugs and alcohol, vandalism is a bigger problem too.” - Key Informant

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Young people face an uncertain future. Their family may be struggling financially, with undependable seasonal employment. A parent may have left the area for another part of the country to seek work, and only comes homes periodically. Young people themselves often leave the area immediately after high school and head “west”. “We face a lot of stress in our lives - from school and from wondering what to do afterwards. There’s no job around here for me.” - Youth Focus Group Participant “Young people just want to get out and make the big money.” - Key Informant

Adults ◆ Economic uncertainly and downturn has characterized the area. People are reluctant to “get their hopes up” but want a better economic situation. “This used to be an affluent area, everyone was working and we had a good standard of living. Now look at it. Everything is slowly deteriorating around here.” - Key Informant

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Many people have left the area to work out of the province. In some cases the families have stayed behind and the wage-earner commutes; other families have left for good. Many people with stable jobs (teachers, health care workers) live in the greater St. John’s area and commute to the Southern Avalon. “Our decreasing population means that some services are being pulled out.” - Focus Group Participant

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Significant numbers of people are struggling to raise a family on low incomes. “There are a lot of people on income support around here.” - Key Informant

Older Adults (seniors) ◆ Many older adults need additional social support. With increased out-migration they don’t have the same family network to depend on. “So many of our seniors live alone - their family has gone to Alberta. Some of them are scared to leave their homes.” - Focus Group Participant “We’re all living alone, our children are living away.” - Senior Focus Group Participant “Seniors are the forgotten people.” - Focus Group Participant ◆

Many older adults have supportive care/housing needs. Many prefer to stay in their own homes, but need help with home repairs; some need home support or another type of supportive housing. They want to stay in their area to receive the service. “Who am I going to call when I need repairs done on my home? My family isn’t here anymore.” Focus Group Participant

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Living on a fixed income and lack of transportation are special concerns of seniors in rural areas. “People really depend on the free (pharmacy) delivery service.” - Key Informant “People need to get organized and plan programs - there are opportunities for meeting seniors’ needs.” Key Informant

Communities ◆ Shrinking populations are having an impact on communities. Some communities are struggling to keep local organizations going; the same people are volunteering and the number of volunteers is diminishing. “We’ll never return to the “glory days”, but we need to figure out how to make our community work with fewer people.” - Key Informant “I hear a lot about volunteer burn-out.” - Key Informant “Rural life is at the tipping point.” - Key Informant ◆

Some communities are facing challenges in maintaining continuity of some public services, including physician services. “We live in a sparsely populated rural area; we have to pay the price.” - Focus Group Participant “We need stable medical services and a team approach.” - Focus Group Participant

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Communities are starting to think regionally about the issues. In some instances, they are taking action together. “We have to realize and accept that we have a problem. When you have a community that’s more aware, it is more humane.” - Focus Group Participant “Networking needs to happen. Communities could work closer together. We saw that with Festival of the Sea.” - Focus Group Participant “We’ve come a long way in thinking and acting as a region.” - Key Informant “Community partnership is very important in promoting healthy communities.” - Key Informant

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Communities have ideas and commitment to tackle the issues related to health and wellness. They offered lots of examples of efforts underway. “People need to get organized and plan programs to respond to the needs.” - Focus Group Participant “Our seniors’ group has a lot of programs on the go - we have a responsibility to the people who live here.” - Seniors Focus Group Participant “Our Moving for Health Group is working really well and we enjoy the chance to get together with other communities who are doing the same thing. We get ideas from each other.” - Focus Group Participant “We decided to focus on the Food Bank issues - people need to have access to good food.” Focus Group Participant “People in rural areas need to bond. That’s part of the reason we developed our program this winter at the Father Val Power Centre.” - Focus Group Participant

Conclusions Based on the challenges they are facing, the people of the Southern Avalon told us that they need: ◆

More emphasis on health promotion and support for communities to develop the skills and capacity to pursue health promotion.

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Primary health care that is stable, dependable, team-based and innovative in responding to the needs of rural areas.

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Accessible mental health and addictions services.

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Support for an aging population.

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A health system that is easy to understand and “navigate”.

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Staff that respect them as partners and are willing to work in collaboration with people and communities.

The Southern Avalon Community Health Needs Assessment has given Eastern Health an opportunity to learn about the needs of the area. We have had a dialogue with community members about the challenges to health and wellness in the region and have discussed some potential solutions. Communities have offered ideas and want positive change - they are moving forward with strategies that are making a difference. Eastern Health has a responsibility to partner with communities in responding to the challenges identified in this community health needs assessment and supporting activities “on the path to health and wellness.” We commit to this challenge and look forward to this partnership.

Recommendations (Organizational/Administrative) 1. Communicate the results of the Southern Avalon Community Health Needs Assessment broadly to the public, key informants, focus group participants, Eastern Health staff and physicians, and key partners. 2. Provide the Board of Trustees of Eastern Health with a semi-annual written status report regarding progress on implementation of the recommendations. 3. Provide the public with a status report, two years from the release date of the Southern Avalon Community Health Needs Assessment, regarding progress on implementation of recommendations of this report. 4. Develop a systematic executive-level plan to review, and, where necessary, revise Eastern Health’s policies and programs to ensure consistency in provision of programs and services across the region. 5. Implement a mechanism(s) throughout the Eastern Health region to ensure Eastern Health programs and services are communicated in a user-friendly and accessible way to the public (including clients, patients, residents and families), our partners and our staff. Investigate feasibility of the following options: I. 1-800 telephone system serving the entire Eastern Health region supported by accessible database of services/forms/program data. II. Web-based information system (services/forms/program data) accessible to the public, partners and staff. (Modelled on 1-800-O Canada)

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6. Request that the Information Management Committee of Eastern Health develop a plan to improve the integrity and integration of the community-based management information systems. 7. Enhance capacity of Eastern Health staff to work effectively with individual and community partners through the development of targeted education and training opportunities. 8. Identify ways to mutually strengthen and support the partnership between Family Resource Centres and Eastern Health. 9. Advocate with external partners for continued implementation of the provincial government’s Poverty Reduction Strategy (Reducing Poverty: An Action Plan for Newfoundland and Labrador, June 2006.) 10. Establish mechanisms for working partnerships with the education system (Eastern District School Board, Department of Education), the justice system (RCMP, court system), and Human Resources Labour and Employment (HRLE).

Recommendations (based on Eastern Health’s Lines of Business) Promote Health and Well-Being 1. Ensure Eastern Health’s health promotion plan (expected release date fall 2007) includes initiatives that address the particular needs of rural areas. The following specific areas for health promotion/health promotion delivery have been identified: a. Seniors’ health promotion (in light of the significant aging of the population). b. Mental health promotion (noting the need for community support/partnerships and the role of all members of the rural primary health care team). c. Pre-school and school health promotion strategies. d. Dental (oral) health promotion (in light of findings related to poor oral health). e. Accessible, affordable community-based health programming (such as Moving for Health programs). f. Innovative methods of communicating health promotion messages. 2. Identify opportunities to expand the School Health Team model to the entire Southern Avalon area of Eastern Health. 3. Advocate to strengthen Eastern Health’s health promotion capacity/linkage with the school system. 4. Establish a community grants fund, administered through Eastern Health, to support community-initiated projects at the community level. 5. Explore the possibility of expanding the Celebrating Rural Health initiative to two events in the Southern Avalon area (Irish Loop and Avalon Gateway), within two years of the release of this report. 6. Advocate with the Eastern School District and Department of Education to increase community groups’ ability to access schools for health-related activities and initiatives.

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Provide Supportive Care: 1. Convey findings of Southern Avalon Community Health Needs Assessment to Newfoundland and Labrador Housing Corporation (NLHC). 2. Initiate a liaison committee between NLHC and Eastern Health to promote effective partnerships and improved supportive housing programs, such as the home repair program. 3. Conduct a comprehensive analysis of future long term care bed needs in the Placentia area (Lionâ&#x20AC;&#x2122;s Manor), in light of significant aging of population. 4. Standardize home support policies and procedures across Eastern Health region to ensure clients receive the same information and level of service. 5. Advocate with the Department of Health and Community Services for changes to the home support program that would help streamline the financial assessment process and increase access to low level supports.

Treat Illness and Injury: 1. Develop a primary health care framework that addresses strategies for the delivery of services in the Southern Avalon, with particular attention to team development, scope of practice, physician retention issues and community linkages. 2. Promote linkages between community pharmacists and other members of the primary health care team by discussing and implementing means to facilitate improved communication, teamwork and patient/client care. 3. Develop a plan to address current and future needs of the laboratory and X-ray service at Trepassey, incorporating consideration of present and future human resource requirements and equipment needs and involving all partners including Eastern Healthâ&#x20AC;&#x2122;s regional Diagnostic Imaging and Laboratory Medicine departments. 4. Evaluate blood collection needs in rural areas of the Southern Avalon, to determine business case for potential innovations in service. 5. Advocate that the provincial government address oral health needs and gaps through expanded dental services by a) enhancing services offered to persons on income support and those with low income, and b) considering the provision of mobile clinics for rural areas currently underserved by dental services supported, where possible, by Eastern Health space. 6. Provide a status report to the organization and the community regarding implementation of Eastern Healthâ&#x20AC;&#x2122;s Regional Action Plan for Mental Health and Addictions, with particular focus on outstanding issues related to rural service recommendations. Continue to advocate for funding for current plan. 7. Improve our understanding of the impact of chronic disease (or specific chronic diseases) in the Eastern Health region by collecting and analysing region-specific surveillance and intervention data. 8. Partner with the Department of Health and Community Services in developing and implementing a chronic disease management strategy that is consistently applied across the Eastern Health region.

The Southern Avalon: Quick Facts DATA SOURCES: Statistics Canada 2006 census data; Community Accounts (Newfoundland and Labrador Statistical Agency); 2001 Newfoundland and Labrador Adult Health Survey Irish Loop - corresponds to Economic Zone 20 (Bay Bulls to Riverhead, St. Mary’s Bay) Avalon Gateway - corresponds to Economic Zone 18 (Admiral’s Beach to Long Harbour)

1. Demographics ◆

Irish Loop population declined 4.8% from 2001-2006 (Statistics Canada 2006 census data released March 2007). Total population for the Irish Loop in 2006 is 8,261.

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Avalon Gateway population declined 8.2% from 2001-2006 (Statistics Canada 2006 census data released March 2007). Total population for Avalon Gateway in 2006 is 7,903.

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People aged 65 years and older are projected to make up over 30% of the total population of the Southern Avalon by 2021. This projection indicates that the Southern Avalon will be the “oldest” area in the Eastern Health region.

2. Incomes ◆

Avalon Gateway has lower personal income per capita and lower average family income than the Irish Loop. (2004 data)

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Compared to the rest of the economic zones in the Eastern Health region, Avalon Gateway income levels are lower than most; Irish Loop levels are higher than most. (2004 data)

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Avalon Gateway’s personal income per capita is 14.5% lower than the provincial level while the Irish Loop’s personal income per capita is 7.7% lower than the provincial level. (2004 data)

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Avalon Gateway’s average couple family income is 6% lower than the provincial average; the Irish Loop’s average couple family income is 5% higher than the provincial average. (2004 data)

3. Employment ◆

Avalon Gateway has a lower employment rate than the Irish Loop (75.1% compared to 79.1% - 2003 data). This compares to a provincial employment rate of 76.5% (2003 data)

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There was a 2.2% drop in the employment rate in Avalon Gateway from 1998-2003; the Irish Loop employment rate grew by 1% in the same period. For the same period, employment in the province grew by 5.9%.

4. Education ◆

Avalon Gateway has slightly more high school graduates than the Irish Loop (56.9% of the population compared to 55.3%) but fewer people with a Bachelor’s degree or higher (4.7% in Avalon Gateway compared to 7.2% in the Irish Loop - 2001 data.)

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High school graduation rates for the Southern Avalon are slightly lower than the provincial high school graduation rate of 60%. (2001 data)

5. Self-Assessed Health Status ◆

In the Irish Loop, 89% rated their health as good, very good or excellent in the 2001 Newfoundland Adult Health Survey; in Avalon Gateway, 84% rated their health as good, very good or excellent. This compares to 86% of the provincial sample who rated their health as good, very good or excellent. (2001 data)

Table of Contents 1. Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .I 2. Synopsis & Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .II 3. Introduction

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3.1. What is a Community Health Needs Assessment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 3.2. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 3.3. The Community Health Needs Assessment Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 4. Methodology

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

4.1. The Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 4.2. Population Health Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 4.3. Managing the Needs Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 4.3.1. Steering Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 4.3.2. Advisory Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 4.4. Primary Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 4.4.1. Key Informant Interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 4.4.2. Focus Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 4.4.3. Telephone Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 4.4.4. Submissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 4.5. Secondary Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 4.6. Validating Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 4.7. Comparison Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 4.8. Communications Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 5. The Southern Avalon - Past, Present and Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 5.1. The Southern Avalon - History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 5.2. The Southern Avalon - Today . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 5.3. The Southern Avalon - The Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 5.4. The Southern Avalon - Public Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 6. An Overview of Key Health Status Indicators: Southern Avalon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 6.1. Community Well-Being Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 6.2. Mortality Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 6.3. Incidence of Chronic Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 6.4. Self-Assessed Health Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 7. Determinants of Health (Health Services) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 7.1. Promote Health and Well-being . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 7.1.1. Overview of Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 7.1.2. Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 7.1.3. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

7.2. Provide Supportive Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 7.2.1. Overview of Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 7.2.2. Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 7.2.3. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 7.3. Treat Illness and Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 7.3.1. Overview of Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 7.3.2. Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45 7.3.3. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 8. Determinants of Health (Other) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 8.1. Income and Social Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 8.2. Employment and Working Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64 8.3. Social Support Networks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 8.4. Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70 8.5. Social Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 8.6. Physical Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72 8.7. Personal Health Practices and Coping Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76 8.8. Healthy Child Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81 8.9. Biology and Genetic Endowment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84 8.10. Gender and Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84 8.11. Conclusions - Determinants of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 9. Eastern Health - The Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 9.1. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 10. Conclusion

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88

Table of Figures Figure 1: Map of Eastern Health (Southern Avalon Region Outlined) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Figure 2: Eastern Healthâ&#x20AC;&#x2122;s Vision Linked to the Determinants of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Figure 3: Breakdown of Southern Avalon into Telephone Survey Sub-Regions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Figure 4: Population Change in Economic Zone 20 - Irish Loop, 1986-2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Figure 5: Student Enrolment in Economic Zone 20 - Irish Loop, 1989-2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Figure 6: Select School Enrolment; Irish Loop (Economic Zone 20) 1998-2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Figure 7: Population Change in Economic Zone 18 - Avalon Gateway, 1986-2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Figure 8: Student Enrolment in Economic Zone 18 - Avalon Gateway, 1989-2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Figure 9: Select School Enrolment: Avalon Gateway (Economic Zone 18) 1998-2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Figure 10: Projected Aging of Population (Southern Avalon, Eastern Health, Province) . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Figure 11: Projected Population, Eastern Health Regions (65+ as Percentage) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Figure 12: Causes of Death, Avalon Gateway (Economic Zone 18) - 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Figure 13: Causes of Death in the Irish Loop (Economic Zone 20) for 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Figure 14: Comparison of Causes of Death by Disease Chapter 2003 (Economic Zone 18 - Avalon Gateway, Economic Zone 20 - Irish Loop, Eastern Health, Province of NL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Figure 15: 2001 Newfoundland and Labrador Adult Health Survey, Self-Assessed Health . . . . . . . . . . . . . . . . . . . . . . . . . .28 Figure 16: Self-Assessed Health Status, Southern Avalon Telephone Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Figure 17: Economic Self-Reliance Ratio (2004) Eastern Health Economic Zones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 Figure 18: Social Assistance Incidence (2003) Eastern Health Economic Zones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61 Figure 19: Personal Income Per Capita (2004) Eastern Health Economic Zones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61 Figure 20: Average Couple Family Income (2004) Eastern Health Economic Zones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62 Figure 21: Employment Rate (2003) Age 18-64 Eastern Health Economic Zones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65 Figure 22: Change in Employment, 1998-2003, Eastern Health Economic Zones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66 Figure 23: Employment Insurance Incidence (2004) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66 Figure 24: Migration Rates (1991-1996) Eastern Health Economic Zones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 Figure 25: High School Education or Above (2001) Age 20+, Eastern Health Economic Zones . . . . . . . . . . . . . . . . . . . . .70 Figure 26: Bachelorâ&#x20AC;&#x2122;s Degree or Higher (2001) Ages 21-54, Eastern Health Economic Zones . . . . . . . . . . . . . . . . . . . . . . .71 Figure 27: Breastfeeding Initiation as a Percentage of Live Births, Southern Avalon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82

Table of Tables Table 1:

Composition of Respondents’ Household Members by Age and Region, Southern Avalon Telephone Survey . . . . . . .9

Table 2:

Age Distribution of Respondents’ Household Members (Southern Avalon Sample, Burin Sample, Newfoundland and Labrador, and Canada) . . . . . . . . . . . . . . . . . . . . . . . . .10

Table 3:

Gender of Respondents, Southern Avalon Telephone Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Table 4:

Age Distribution of Respondents, Southern Avalon Telephone Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Table 5:

Public Infrastructure in the Southern Avalon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Table 6:

Comparison of Well-Being Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

Table 7:

2001 NL Adult Health Survey, Self-Reported Diagnosed Chronic Conditions (Respondents M/F Aged 18+) . . . . . .25

Table 8:

2003 Canadian Community Health Survey: Self-Reported Diagnosed Chronic Conditions (Respondents M/F Aged 12+) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Table 9:

Hospital Discharges Related to Chronic Conditions (Top Ten Case Mix Groups Related to Chronic Conditions, Southern Avalon Patients 2003-2006) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Table 10: 2003 Canadian Community Health Survey: Self-Assessed Health/Mental Health Status (Respondents Aged 12 Years and Older) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Table 11: Promote Health and Well-Being - Southern Avalon Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 Table 12: Average Number of Referrals (per Month) to Child, Youth and Family Services, Southern Avalon (2004-2006) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Table 13: Foster Homes, Average (Monthly) Number of Children in Foster Care, Southern Avalon (2004-2006) . . . . . . . . . . .36 Table 14: Long Term Protection Cases (Average per Month) Southern Avalon (2004-2006) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 Table 15: Youth on Probation and in Custody (Average per Month) Southern Avalon (2004-2006) . . . . . . . . . . . . . . . . . . . . . .37 Table 16: Provide Supportive Care - Southern Avalon Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 Table 17: Home Support Admissions/Costs, Southern Avalon (2004-2007) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 Table 18: Lions Manor (Placentia) Occupancy Rates and Wait List (2003-2006) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 Table 19: Placentia Health Centre, Case Mix Groups* with 10+ Days Length of Stay (2003-2006) . . . . . . . . . . . . . . . . . . . . . . .41 Table 20: Admissions to St. John’s Area Nursing Homes (Southern Avalon Residents, 2004-05; 2005-06) . . . . . . . . . . . . . . . . .42 Table 21: Number of Alternative Family Care Homes and Number of Individuals Placed, Southern Avalon (2003-2006) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 Table 22: Treat Illness and Injury - Southern Avalon Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 Table 23: Additional Primary Health Care Services Available to Residents of the Southern Avalon (External to Eastern Health) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45 Table 24: General Practitioners Serving the Southern Avalon: (March 2007) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45 Table 25: Location of Family Doctor by Region, Southern Avalon Telephone Survey, 2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 Table 26: History of General Practitioner Coverage: Placentia Health Centre (2003 to Date) . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 Table 27: History of General Practitioner Coverage, St. Mary’s/Mt. Carmel Clinic (2003 to Date) . . . . . . . . . . . . . . . . . . . . . . . .47

Table 28: History of General Practitioner Coverage, Shamrock Clinic, Ferryland (1996 to Date) . . . . . . . . . . . . . . . . . . . . . . . . .48 Table 29: Number of Respondents with a Family Doctor (by Region), Southern Avalon Telephone Survey 2006 . . . . . . . . . . .48 Table 30: Length of Time with the Same Family Doctor, Southern Avalon Telephone Survey 2006 . . . . . . . . . . . . . . . . . . . . . . .49 Table 31: Wait Times to Get an Appointment with a Family Doctor, Southern Avalon Telephone Survey 2006 . . . . . . . . . . . . .49 Table 32: Utilization of Nurse Practitioner Service, St. Mary’s/Mt. Carmel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 Table 33: Respondents who Visited the Dentist in the Last Twelve Months, Southern Avalon Telephone Survey, 2006 . . . . . . .52 Table 34: Dental Surgery ( ups, Placentia Health Centre, 2003-2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 Table 35: Ambulance Transports: Trepassey, St. Mary’s and Mt. Carmel (2003-2006) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 Table 36: Service Counts, Rehabilitative Services, Southern Avalon 2003-2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 Table 37: Health Line Utilization, Southern Avalon October 2006 - January 2007 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 Table 38: Top Five Case Mix Groups, Placentia Health Centre, 2003-2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 Table 39: Top Five Case Mix Groups, Carbonear General Hospital (Southern Avalon Patients, 2003-2005) . . . . . . . . . . . . . . . .57 Table 40: Top Five Case Mix Groups, St. John’s Adult Acute Hospitals (Southern Avalon Patients, 2003-2005) . . . . . . . . . . . . .57 Table 41: Top Five Case Mix Groups, Janeway Child Health Centre (Southern Avalon Patients, 2003-2006) . . . . . . . . . . . . . . .58 Table 42: Incidence of Respondents At/Below Low Income Cut-Off by Region, Southern Avalon Telephone Survey . . . . . . . .63 Table 43: Public Transportation Availability on the Southern Avalon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 Table 44: Distance and Driving Times, Selected Communities - Southern Avalon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 Table 45: Reported Consumption of Five Fruits and Vegetables Daily, Southern Avalon Telephone Survey . . . . . . . . . . . . . . . .77 Table 46: Percentage of Population Aged 12 and Older who Consume 5 to 10 Servings of Fruit and Vegetables Daily (2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77 Table 47: Participation in Physical Activities, Southern Avalon Telephone Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77 Table 48: Percentage of Population Aged 12 Years and Older who Report Being Active or Moderately Active, 2003 . . . . . . . . .78 Table 49: Percentage of Population (2003) who are Overweight (BMI 25-29.9) or Obese (BMI 30+) . . . . . . . . . . . . . . . . . . . . .78 Table 50: Daily Smoking, Southern Avalon Telephone Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79 Table 51: Percentage of Population 12 Years and Older who are Current Daily Smokers, 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . .79 Table 52: Consumption of Alcohol: More Than 7 Drinks per Week, on Average, Southern Avalon Telephone Survey . . . . . . .80 Table 53: Spending Over $20 per Week on Gambling, Southern Avalon Telephone Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81 Table 54: Availability of Service: Family Resource Centres Serving the Southern Avalon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83 Table 55: Program Utilization (Participation in at Least One Program) Family Resource Centres, Southern Avalon (2005-2006) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83 Table 56: Births Requiring Healthy Beginnings Long-Term Follow-up (2003-2006) Southern Avalon . . . . . . . . . . . . . . . . . . . .83 Table 57: Self-report of Breast Exam by Physician or Nurse, Southern Avalon Telephone Survey (2006) . . . . . . . . . . . . . . . . . .85 Table 58: Cervical Cancer Screening, Southern Avalon Telephone Survey (2006) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86 Table 59: Prostate Cancer Screening, Southern Avalon Telephone Survey (2006) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86

Table of Appendices Appendix A: Terms of Reference - Steering Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95 Appendix B: Terms of Reference - Advisory Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97 Appendix C: List of Key Informants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99 Appendix D: Standardized Questionnaire Used to Guide Key Informant Interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102 Appendix E: Representatives/Organizations Invited to Attend a Focus Group Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104 Appendix F: Standardized Questionnaire Used to Guide Focus Group Discussions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111 Appendix G: Standardized Questionnaire Used to Guide Youth Focus Group Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113 Appendix H: Southern Avalon Community Health Needs Assessment Telephone Survey Report . . . . . . . . . . . . . . . . . . . . . . . .115 Appendix I: Complete List of Secondary Resource Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .186 Appendix J: Listing of Eastern Health Staff Consulted on Issues Arising From the Community Health Needs Assessment . .191 Appendix K: Newsletters Circulated During the Community Health Needs Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .193 Appendix L: Geographic Overview of Health Services Offered on the Southern Avalon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .200 Appendix M: Infrastructure Assessment, Southern Avalon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .205

3. Introduction Eastern Health was formed on April 1, 2005, from the merger of seven health care organizations. Eastern Health provides the full continuum of health services, including community, acute and long-term care. It is the largest health services organization in the province of Newfoundland and Labrador and has both regional and provincial responsibilities. As seen in the figure below, the Eastern Health region extends west from St. John’s to Port Blandford and includes all communities on the Avalon, Burin and Bonavista Peninsulas.

Figure 1: Map of Eastern Health (Southern Avalon Region Outlined)

The Southern Avalon area (population 16,164 - 2006 Census)3 , outlined by a solid line on the map in Figure 1, is the second area within Eastern Health to participate in a community health needs assessment. (The Burin Peninsula was the first: Navigating the Way Together: Burin Peninsula Community Health Needs Assessment was released in June 2006). The Southern Avalon extends from Bay Bulls along the Southern Shore to Trepassey and St. Shott’s; along the east side of St. Mary’s Bay to the Salmonier area and Colinet; along the west side of St. Mary’s Bay to Branch and the Cape Shore to Placentia; and along the east side of Placentia Bay to Long Harbour-Mt. Arlington Heights. The Southern Avalon corresponds to two economic zones - the Irish Loop (Economic Zone 20) and Avalon Gateway (Economic Zone 18). This geographic area includes the communities on the Southern Shore from Bay Bulls to St. Shott’s, all the communities in St. Mary’s Bay from St. Vincent’s-St. Stephen’s-Peter’s River to North Harbour and from Branch on the Cape Shore to Long Harbour-Mt. Arlington Heights. Three former health boards managed services in this area prior to the formation of Eastern Health - the Avalon Health Care Institutions Board, Health and Community Services Eastern, and Health and Community Services, St. John’s Region.

3.1. What is a Community Health Needs Assessment? A community health needs assessment gathers information about the health-related needs of a particular area from both a factual and an opinion perspective. The assessment identifies key themes, prioritizes needs, develops recommendations and lays out an action plan. In this way, information is translated into knowledge that can be used for action. Eastern Health is undertaking community health needs assessments of specific areas within its boundaries because the Board of Trustees and the organization’s staff recognize the benefits that can occur from the process.4 A community health needs assessment can provide the organization with a better understanding of what a community needs in order to maintain and improve health. This understanding comes about by reviewing a variety of data, both qualitative and quantitative. Qualitative data (results of opinions and perceptions gathered in focus groups, key informant interviews and a telephone survey) is examined along with quantitative data (utilization information, demographic and other trends, health status information) to identify the health-related needs of the area. Because the community health needs assessment process involves direct conversations with many people in the area, it also increases dialogue and builds partnerships between Eastern Health and the community. The dialogue “puts a face” on both the community and the organization and gets people talking about health, the challenges they face in maintaining and promoting health, the “good news” stories related to health in their region and the ways that Eastern Health can organize and deliver its services to support health and wellness. A fundamental belief of the organization is that communities have the capacity to identify challenges, but also to know how to respond to these challenges. Eastern Health, working independently, cannot respond optimally to the healthrelated challenges that are identified. Some solutions may come about as a result of changes or modifications to programs offered by Eastern Health. More often the solutions to the challenges may require partnerships between Eastern Health and the community and/or other organizations, and the solutions may need to be implemented over a period of time. However, the first step in meeting the needs is to recognize the challenge together, identify solutions, and decide to take action.

3.2. Limitations Any research is undertaken within limitations that have an impact on the process and outcomes. It is important to make an effort to minimize these limitations by using multiple approaches to data collection and by seeking different perspectives. In an effort to minimize limitations, this community health needs assessment used a mixed methodology approach for community and individual consultation (key informant interviews, focus groups, random telephone interviews, a public call for verbal or written submissions, and a community Advisory Committee). Recognizing the inherent challenges in meeting with some groups of people (such as persons with disabilities, frail elderly and people living in poverty) the researcher made an effort to have discussions with people knowledgeable of the issues who could describe and advocate for the needs of these individuals. Limitations having an impact on this community health needs assessment include the following: ◆

The telephone survey data reflects the opinions of predominately older, female respondents (75.8% of respondents were female; 64.1% of respondents were 50 years or older).

◆

Internal utilization data was sometimes difficult to obtain, as information systems from four of the former health boards were used as data sources. Data was not always documented in a similar manner, making it difficult to obtain and compare information.

◆

Events occurring in the Southern Avalon during the time period of the community health needs assessment may have had an impact on the process and/or the comments received during the process. ✧

Voisey’s Bay Nickel Company changed the location of their much-anticipated nickel processing facility to Long Harbour from Argentia and they announced compensation for the town of Placentia.

✧

Renovations to the St. Mary’s Health Clinic occurred concurrently with the needs assessment, resulting in temporary placement of some staff and services in the provincial Department of Works, Services and Transportation building.

✧

Discussions and consultations about emergency health services (ambulance transport) within the Eastern Health region were taking place at the same time as the needs assessment.

3.3. The Community Health Needs Assessment Report This community health needs assessment describes the community health needs assessment process and the Southern Avalon region, highlights the specific health-related issues identified during the assessment process, and itemizes the recommendations. It is presented with a fairly detailed synopsis (Section 2) that is an easily accessible stand-alone summary of the process, the findings and the recommendations. The full report provides more detail on the community health needs assessment process, and the specific findings related to health status in the Southern Avalon and the determinants of health. It includes: Background on the community health needs assessment and the methodology used (Sections 3 and 4) A brief history of the Southern Avalon region and a summary of the current situation (Section 5) ◆ An analysis of some key population health indicators for the Southern Avalon region (Section 6) ◆ Findings and recommendations related to the health services determinant of health (Section 7) ◆ Findings and recommendations related to the other determinants of health (Section 8) ◆ Findings and recommendations related to Eastern Health (organizational, administration and partnerships) (Section 9) ◆ Conclusion (Section 10) ◆ ◆

Recommendations are included in the synopsis and provided in context within the findings of each section.

4. Methodology 4.1. The Plan The Southern Avalon Community Health Needs Assessment plan follows the format suggested by Cavanagh and Chadwick in their document Health Needs Assessment (2005)5 and builds on the experience of the Burin Peninsula Community Health Needs Assessment in 2006.6 The plan included five steps. Steps in the Community Health Needs Assessment7 Step 1: Getting Started Step 2: Identifying Health Priorities Step 3: Assessing a Health Priority for Action Step 4: Planning for Change Step 5: Moving on/Review The Southern Avalon Community Health Needs Assessment was initiated with a series of community meetings on September 22, 2006 (Placentia, St. Maryâ&#x20AC;&#x2122;s and Trepassey). At these meetings, Mrs. Joan Dawe, Eastern Health Board Chair, provided background information on Eastern Health and indicated how the needs assessment would help the organization obtain valuable information by initiating a dialogue with people in the region. Eastern Health staff described the needs assessment methodology and time lines and community members were encouraged to get involved in the process. Several options for local involvement were suggested such as offering to participate as a member of the Advisory Committee, taking part in a focus group, participating in a telephone survey, or providing a written or oral submission.

4.2. Population Health Approach The WHO (World Health Organization) defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.8 This definition of health supports the use of a population health approach9 to measure the health of communities. Population health is focused on improving the health of a population by understanding and addressing those factors that significantly influence health. These factors (the determinants of health) include things such as the social, economic and physical environments; personal health practices, individual capacity and coping skills, human biology, early childhood development and health services. This approach to assessing the health needs of a population focuses on the determinants of health and how the interaction between these determinants impacts the health of individuals and communities. The overarching goal of a population health approach is to maintain and improve the health status of the populations. In order to do this, we must go beyond focusing solely on the delivery of health services and include analysis and action on the broad determinants of health.10 Figure 2 shows the determinants of health linked to Eastern Healthâ&#x20AC;&#x2122;s vision of Healthy People, Healthy Communities. Eastern Healthâ&#x20AC;&#x2122;s vision can only be achieved if, in addition to addressing negative health outcomes, we examine the impact these determinants of health, acting alone or interacting with each other, have on the people and communities we serve, and as an organization and society, take action on the forces that negatively impact health. The determinants of health and their underlying premises as outlined by the Public Health Agency of Canada11 are:

Income and Social Status People are healthiest when they live in a society that can afford to meet everyone’s basic needs. Once the basic needs are met, people’s health is also affected by how big a difference there is between the richest and poorest members of society. When there are big differences in income within a society, there are also big differences in social status. This has an impact on health because people with lower social status have less control over their lives and fewer chances to make choices for themselves. Research indicates that income and social status is the single most important determinant of health. Social Support Networks People need to feel connected to their community in order to feel healthy. Support from families, friends and communities is associated with better health. This support seems to help people cope when they encounter difficult situations. Education Generally, the more education a person has, the healthier they are. Education gives people the knowledge and skills they need to make healthy choices. Higher education often leads to a better income and a more secure job, and to more participation and involvement in one’s community. Employment/Working Conditions People are healthier when they have a job, when they feel the work they do is important, when their job is secure and when their workplace is safe and healthy. Social Environments A society that values and is inclusive of all persons (recognizing diversity and showing evidence of high levels of volunteerism and active community organizations) can have a positive impact on one’s health. Physical Environments People need to live and work in safe and healthy environments. Clean air and water quality, safe housing and communities, safe workplaces and roads all contribute to good health. Personal Health Practices and Coping Skills Personal health practices, such as whether or not a person smokes or drinks, eats well and is physically active, affects health. A person’s coping skills - how one handles the challenges and stresses that life presents - also has an impact on health. Healthy Child Development The effect of pre-natal and early childhood experiences on a person’s health, well-being and coping skills is very powerful and can affect a person’s health throughout their life-span. Health Services Access to health services, particularly those that maintain and promote health and support healthy choices and lifestyles, help to make people healthier.

Biology and Genetic Endowment The physical traits a person inherits from their family affect health. Genes play a part in deciding how long we’ll live, how healthy we’ll be and the likelihood that we’ll get certain illnesses. Gender and Culture Whether a person is male or female affects their health. Men and women have different life expectancies and get different kinds of diseases and conditions at different ages. Men and women have different risks for violence and sexually transmitted diseases. Some of the differences in the health of men and women are due to biology and some are the result of the differences in the way society treats men and women. Many health issues are a function of genderbased social status or roles. Peoples’ backgrounds, their upbringing, the traditions in their community - all these cultural influences affect health because they influence the way people think, feel, act and what they believe to be important. Gender and culture have an influential effect on all the other health determinants. Eastern Health’s vision of Healthy People, Healthy Communities is rooted in the belief that the determinants of health significantly influence health and well-being, and these determinants are very much linked together and inter-related. People living in communities in some areas within the Eastern Health geography may have greater challenges in maintaining and improving their health, because of the impact of particular health determinants in that particular area. For example, a person without a job, living in an area with few employment options and coping without a social support network (due to out-migration of family and friends) may face greater health and coping challenges than someone with a strong support network living in an area where steady employment is available.

Figure 2: Eastern Health’s Vision Linked to the Determinants of Health

4.3. Managing the Needs Assessment 4.3.1. Steering Committee A Steering Committee (see terms of reference in Appendix A) was struck to help guide the community heath needs assessment. This committee included Eastern Health staff from the Southern Avalon area (both front line staff and managers) and some regional directors. Together they contributed a broad range of perspectives and knowledge of local issues and needs. They approved the plan for the needs assessment, reviewed each step of the process, and provided feedback on the key themes, issues and recommendations. 4.3.2. Advisory Committee An Advisory Committee comprised of community members (see terms of reference in Appendix B) met regularly throughout the needs assessment process to give advice and feedback. Members of the Advisory Committee were from the Southern Avalon and were invited to sit on the committee from those responding to a public call for expressions of interest. Membership on the Advisory Committee was based on each member’s linkages to one or more of the determinants of health. The Advisory Committee provided input into the needs assessment plan, feedback on sections of the report, and discussed the report’s findings and recommendations.

4.4. Primary Research A primary research plan was developed and included key informant interviews, focus groups, a random telephone survey and a public call for written or oral submissions. 4.4.1. Key Informant Interviews A key informant interview is a one-on-one discussion with a person knowledgeable about the geographic area or of a particular aspect of the needs assessment, such as a specific determinant of health. Forty-five key informant interviews took place for the Southern Avalon Community Health Needs Assessment. Suggestions for potential key informants came from a variety of sources (Eastern Health staff, Advisory and Steering Committee members, community leaders). Key informants are people with a broad perspective on the needs of the area or with an expertise in one or more of the determinants of health. (See Appendix C for list of key informants). A standard interview guide was used with each key informant. The questions covered topics such as the informant’s perspectives on the strengths and challenges facing the community, their assessment of the impact of particular determinants of health on the area, the main health-related challenges faced by the people in the area, the barriers people encounter in accessing services, and future needs of the area. Interviews took place in person and via telephone. (See Appendix D for the standardized questionnaire used to guide the discussions). 4.4.2. Focus Groups Common themes identified from the key informant interviews formed the basis for discussion in focus groups. These focus groups provided an opportunity for small groups of participants to talk about issues in a facilitated discussion. Seventeen (17) focus groups were held in three sub-regions (Southern Shore, St. Mary’s Bay/Salmonier and Placentia area). They included meetings with representatives of community organizations (4 focus groups); municipal leaders

(4 focus groups); Eastern Health partner organizations (2 focus groups); providers of service (3 focus groups); Placentia area physicians (1 focus group); Eastern Health consultants involved in health promotion (1 focus group); youth (1 focus group) and seniors (1 focus group). Representatives invited to attend the focus group sessions are listed in Appendix E. Potential focus group members were invited by telephone, letter or personal contact to attend a session. Focus groups were from sixty to ninety minutes in duration; most sessions were audio taped for use by the facilitator and the recorder to ensure accuracy in transcription. Participants signed informed consent forms prior to participating in the focus group. The same question guide was used at each focus group, with the exception of the youth focus group. The questions focused on community issues, health concerns, current community capacity, perceived service gaps and opportunities for improvement in service delivery. The question guides used for focus groups are provided in Appendix F (Standard Focus Group Questions) and G (Youth Focus Group Questions). 4.4.3. Telephone Survey Eastern Health contracted with Tele-link Research Inc. in St. John’s to conduct a telephone survey with a random sample of the population in the Southern Avalon study area. The survey focused on four main themes: ◆ Access to Health Services ◆ Satisfaction with Health Services ◆ Perceptions of Community Problems ◆ Self-Assessment of Personal Health and Wellness For the purposes of more detailed analysis of the telephone data, the Southern Avalon was broken down into three sub-regions:

Region B Portugal Cove South to North Harbour

Region A Bay Bulls to Renews-Cappahayden

Region C Branch to Long HarbourMt. Arlington Heights Figure 3: Breakdown of Southern Avalon into Telephone Survey Sub-Regions

The survey tool used by Tele-link was a revised version of the tool used in the Burin Peninsula Community Health Needs Assessment. Residential telephone numbers were obtained from an electronic database and randomized prior to being loaded into an automatic dialler. Trained telephone interviewers (Eastern Health staff participated in the training of the interviewers) contacted potential participants from the telephone database until an adequate sample was obtained. Respondents were required to be 19 years of age or older. Of the 1652 residents contacted (live answers), 365 consented to be interviewed (22% response rate). The sample size obtained allows for cross comparison among the three areas in the region at a confidence level of 5.06%, 19 times out of 20. The sample of 365 is broken down as follows: ◆ Region A (Bay Bulls to Renews-Cappahayden): 120 persons surveyed ◆ Region B (Portugal Cove South to North Harbour):123 persons surveyed ◆ Region C (Branch to Long Harbour-Mt. Arlington Heights): 122 persons surveyed The initial survey report was analyzed by Tele-link using the SPSS (Statistical Package for the Social Sciences) computer program. Additional in-house analysis was completed to attain a more in-depth review of the data. Health services utilization information provided by respondents is based on the respondents’ recall of events in the year previous to the interview (December 2005-December 2006). The 365 telephone survey respondents were asked to provide details on the make-up of their household. The respondents represented 840 household members or 4.85% of the region’s population. Table 1 describes the composition of the households represented by the telephone survey respondents in the Southern Avalon.

The telephone survey sample population has a noticeably lower percentage of household members under the age of 19 when compared to the provincial and national data, and to the Burin Peninsula telephone sample.12 For example, the sample in Region C has less than half the rate of household members under the age of 19 compared to the provincial and national average. The sample also has a lower rate of dependents than the sample in the Burin Peninsula telephone survey.

Table 3 examines respondents by gender. The gender division for the province is 51.07% Female and 48.93% Male.13 Of Southern Avalon respondents, 75.34% were female; consequently, the sample is biased towards female respondents. Tele-link reports that a female bias is fairly standard for telephone surveys. Almost the same breakdown in gender was reported in the Burin Peninsula telephone survey (76.1% Female and 23.7% Male).14

Table 4 reports the age distribution of respondents and reflects the fact that 84.93% of respondents were over the age of 40. According to Statistics Canada, only 52% of the Canadian population is over the age of 45.15 It appears that the Southern Avalon telephone sample is somewhat older than the general Canadian population. The complete Southern Avalon Community Health Needs Assessment Telephone Survey Report is contained in Appendix H of this report.

4.4.4. Submissions A public call for submissions (oral or written) provided the public with an opportunity to comment on their perception of health and community services needs in the area. Newspaper ads were placed in The Telegram, The Charter and The Shoreline newspapers, and community service announcements were placed on local radio and cable television and in all church bulletins in the needs assessment area. Focus group participants were informed of the opportunity to comment further should they wish to make an individual submission. Eastern Health staff were advised of the opportunity to comment through an article in the internal newsletter, The Loop. Five submissions from the public were received. The general topics of the submissions included: Support for the efforts of the Primary Health Care Renewal Initiative in Placentia Placentia Health Centre issues - emergency care, beds occupied by persons needing placement in long term care, complaint management ◆ St. Mary’s Bay area - suggestions for sustainable primary care, improvements in service (2 submissions) ◆ Concerns re: need for compassionate care, gender issues, issues related to treatment of seniors ◆ ◆

4.5. Secondary Research A significant amount of secondary data was reviewed during the community health needs assessment. Two of the former community health boards, Health and Community Services Eastern and Health and Community Services, St. John’s Region had completed needs assessments that included, but were not limited to, the communities under study in the Southern Avalon.16, 17 The Primary Health Care Renewal Project Proposal for the Placentia Area (2005) and the Client Satisfaction Survey, Baseline Results (June 2005) for this same renewal initiative contained extensive demographic and other service satisfaction data for the Placentia area. Newfoundland and Labrador’s Community Accounts18 is an information source that provides an overview of significant economic, social, and demographic indicators for the province, broken down into multiple regions. The area under review for this community health needs assessment (the Southern Avalon) corresponds to Economic Zone 18 (Avalon Gateway) and Economic Zone 20 (Irish Loop). Through Community Accounts, information was retrieved on a number of significant indicators of well-being for these economic zones, such as demographic trends, health and economic activity and other indicators. The Community Accounts website (http:www.communityaccounts.ca) is an excellent resource for information about a specific area of the province. Utilization information was obtained from internal information management systems, such as Client Referral Management System (CRMS), Meditech and OPIS (the cancer registry). The Newfoundland Centre for Health Information (NLCHI) and the Canadian Institute for Health Information (CIHI) were also valuable references and sources of information for comparative purposes. Eastern Health staff provided detailed utilization and other information in cases where information management systems were incomplete. A review of current facilities and equipment in the Southern Avalon was commissioned by Eastern Health’s Department of Infrastructure Support to coincide with the needs assessment. During the course of the needs assessment, the researcher monitored economic, social and health-related developments in the community health needs assessment area (through local media monitoring, ongoing contact with Steering and Advisory committee members) to keep up-to-date on current developments in the needs assessment area. A complete list of secondary resource material is included in Appendix I.

4.6. Validating Results The Steering and Advisory Committees were presented with primary and secondary data results and themes that emerged from the data review for their validation. The intent was to ensure that the topics emerging from the data collection process resonated with them as genuine issues and needs in their communities. In addition, particular Eastern Health staff members were consulted to validate results and provide insight into the issues raised in the data collection period. A listing of staff consulted is provided in Appendix J.

4.7. Comparison Areas Community Accounts data allows for a comparison of the Southern Avalon (Economic Zone 18 - Avalon Gateway and Economic Zone 20 - Irish Loop) with the other four economic zones that make up the Eastern Health region (Economic Zone 15 - Discovery, Economic Zone 16 - Schooner, Economic Zone 17 - Mariner and Economic Zone 19 - Capital Coast) as well as to the province of Newfoundland and Labrador as a whole. It was also possible to compare data from the Burin Peninsula Community Health Needs Assessment to similar data retrieved for the Southern Avalon. Some data sets were comparable to similar data collected for the province of Newfoundland and Labrador and/or Canada.

4.8. Communications Plan A communications plan was developed to support the needs assessment and to actively engage the people of the Southern Avalon region and other key internal and external stakeholders. In addition to the initial stakeholder meetings, a Southern Avalon Community Health Needs Assessment Newsletter was produced in November, January and March and circulated widely in the needs assessment area through local church bulletins. Copies of the newsletter are in Appendix K. The local media carried news articles on the needs assessment (radio and print) and Eastern Health staff were kept updated through articles in the internal newsletter, The Loop.

5. The Southern Avalon - Past, Present and Future 5.1. The Southern Avalon - History The Southern Avalon, like many areas of rural Newfoundland, has been defined for many years by its proximity to the sea. Nearly all the communities in the region are located alongside or near the ocean, and for many hundreds of years the people have depended on the sea for their livelihood. The area is rich in history and tradition. It was settled initially by a wide variety of nationalities (English, Portuguese, French, Basque and later the Irish) who arrived in the area primarily to exploit the cod fishery. To this day, the area maintains strong links to Ireland, with whom it shares many cultural ties (lately cemented through an annual cultural exchange event, The Festival of the Sea). Many of the communities in the region were initially visited as early as the 15-1600s, with permanent settlement coming later. In the early years, the communities were mostly fishing stations used solely in the fishing season. The rich in-shore cod-fishing grounds attracted fishermen of many nationalities. Over time, the settlements became year-round, but the focus remained on cod and capelin fishing or servicing the fishing industry. A significant settlement occurred at Ferryland on the Southern Shore. This settlement was founded by George Calvert, Lord Baltimore, in 1621 and was originally named Avalon. Its historical significance is important for Newfoundland and Labrador but also for North American colonization. Today it is the site of a significant archaeological dig and interpretation centre. The Cape Race lighthouse is an important landmark. It was here that radio operators were the first to pick up the distress signal from the Titanic, the ocean liner which struck an iceberg 400 kilometres to the south and sank with a huge loss of life in 1912. Nearby, Trepassey was the starting point for several transatlantic flights, including the one in 1928 when Amelia Earhart, as a passenger, became the first woman to fly the Atlantic. Fishing and fish processing were important components of the Southern Avalon economy for many years until the collapse of the cod fishery. In 1991, the Fishery Products International (FPI) Plant in Trepassey closed and, following the cod moratorium in 1992, many smaller fish plants in the area closed as well. This was a major blow for the entire region; the FPI plant had been a significant year-round employer (up to 1000 plant workers year round) drawing people from Trepassey and many surrounding communities. Placentia is the largest community in the Southern Avalon. Its unique central geographic location and splendid natural harbour made it an ideal spot for drying fish; it has a long history associated with the fishery. As the base of the resident fishery it attracted fishermen from a wide variety of places in Europe - including the Basque country in southwest France, Spain and Portugal, the Atlantic coast of France and, after 1713, from southwest England and southeast Ireland. In the early days of the 17th century, Placentia (Plaisance) was the French capital of Newfoundland and an important military centre. The area was garrisoned by the French and the first hospital in Newfoundland was built there. Military occupation would be a feature of Placentia for 150 years after the initial fortifications were built. The English takeover of Placentia (1713) led to a large influx of Irish Catholic families that were brought to the area, originally as fishing servants, by Saunders and Sweetman, a British company. By the 1760s, Placentia was thriving and said to be larger than St. Johnâ&#x20AC;&#x2122;s. The Castle Hill National Historic Park, opened in 1973, commemorates and interprets Placentiaâ&#x20AC;&#x2122;s rich past.

A key historical event took place in 1941, in Ship Harbour, Placentia Bay where the Atlantic Charter was signed by Roosevelt and Churchill. This significant text is regarded as the foundation document upon which the United Nations Charter was later based. Argentia, the site of an American naval operating base established in 1939, was a significant economic driver in the area for many years. This base drew workers from the surrounding communities; the economic structure of the town and local area changed dramatically because of its influence. During the heyday of the Argentia base, with many of the local residents earning good wages, the town of Placentia developed as a bustling local service centre. The closure of the base in 1994 marked the end of an era for the area. Another site of heavy industry was the ERCO phosphorus plant in Long Harbour which operated from 1968 to 1989 and at its peak employed 700 people. Another development impacting the area over the years included the inauguration of the Argentia-North Sydney summer ferry service in 1967 and its associated tourism impact. Since the closure of the Argentia base and the ERCO plant, the Argentia Management Authority and the Long Harbour Development Corporation have aggressively marketed the area with hopes that more development and associated economic spin-offs would help to replace lost jobs. The smaller communities surrounding Placentia and the Cape Shore, as well as those in the St. Mary’s Bay area have had a long association with fish harvesting and processing and their economies have long been dependent on fish quotas and catches.

5.2. The Southern Avalon - Today Population decline is having a significant impact on the Southern Avalon and its communities; this phenomenon was widely acknowledged during key informant and focus group meetings. When residents of the Southern Avalon were asked during the random telephone survey to indicate the most important issue in their community that was having an effect on the health and well-being of the people, 68% indicated that out-migration was the major problem. Anecdotal comments received during the course of the community health needs assessment indicated that the population was continuing to drop in many communities because people were leaving the area to obtain employment elsewhere. This trend was confirmed with the release of 2006 census data (March 14, 2007) that showed a 6.4% drop in the population of the Southern Avalon from the 2001 census.19 This population decline can be analyzed more clearly by examining the population trends in both the Irish Loop (Economic Zone 20 - Bay Bulls to Riverhead, St. Mary’s Bay) and Avalon Gateway (Economic Zone 18 - Admiral’s Beach to Long Harbour-Mt. Arlington Heights). The Irish Loop (Economic Zone 20) area of the Southern Avalon includes a population of approximately 8,261 (2006 Statistics Canada census data20). It includes 18 communities organized into towns and local service districts as well as some unincorporated communities. The towns include Bay Bulls, Aquaforte, Cape Broyle, Fermeuse, Ferryland, Gaskiers-Pt. La Haye, Port Kirwan, Portugal Cove South, Renews-Cappahayden, Riverhead, St. Mary’s, St. Shott’s, Trepassey and Witless Bay. The Irish Loop area also includes the local service districts of Burnt Cove-St. Michael’sBauline East, Calvert, Mobile and Tors Cove.

The population for the Irish Loop area has been in steady decline since 1986 with a pronounced decline of 12.5% in the period from 1996-200121. Figure 4 demonstrates this change and indicates a further decline of 4.8% between the years of 2001 and 2006.22 Some communities in the Irish Loop experienced an even more dramatic population decline in this period (Trepassey - a population decline of 14.2%, St. Shottâ&#x20AC;&#x2122;s - a decline of 24.3%, Fermeuse - a decline of 28.5%, Ferryland - a decline of 12.9%) while the community of Bay Bulls noted a population increase of 6.3%.23 The population for the Irish Loop region is expected to continue to decline slightly over the next 13 years. In a projected population table (medium scenario) prepared by the Economics and Statistics Branch of the Department of Finance in September 2006, the total population of Economic Zone 20 - Irish Loop is expected to fall from 8,904 (2001) to 7,839 (2021).24 The population decline can be seen dramatically in Figure 5 which describes the decline in school enrolment between 1989 and 2006.

Data Source: NL Statistical Agency, Community Accounts, Demographic Accounts (Economic Zone 20) and Statistics Canada, 2006 Census

Data Source: NL Statistical Agency Community Accounts, Education Accounts (Economic Zone 20)

Figure 6, showing the enrolment decline for specific schools in Economic Zone 20 - Irish Loop, portrays a stark example of population trends in the area.25 The population of Economic Zone 18 - Avalon Gateway area is approximately 7,903 (2006 Statistics Canada Census data26). It includes the communities of Placentia (including Jerseyside, Dunville, Ferndale and Southeast Placentia), Admiral’s Beach, Branch, Colinet, Fox Harbour, Long Harbour-Mt. Arlington Heights, Mount Carmel-Mitchell’s Brook-St. Catherine’s, Point Lance, St. Bride’s, St. Joseph’s and the local service districts of Forest Field-New Bridge, North Harbour, O’Donnell’s and Patrick’s Cove-Angels’ Cove, as well as several unincorporated communities.

Data Source: NL Statistical Agency, Community Accounts, Education Accounts

Compared to the Irish Loop area, Economic Zone 18 - Avalon Gateway region has experienced a greater population decline from 1996-2001 (a 13.6% drop in population in Avalon Gateway area as compared to 12.5% for the Irish Loop in the same time period). This population drop is illustrated in Figure 7 which also incorporates the most recent census data for 2006. Data from Statistics Canada’s 2006 census indicates that the population in Economic Zone 18 - Avalon Gateway has had another significant decline (down 8.2% from the 2001 census population). Some communities in this area have had an even more dramatic decline in population (Long Harbour-Mt. Arlington Heights - a decline of 41.7%, Placentia - a decline of 11.9%, Point Lance - a decline of 16.2%, St. Bride’s - a decline of 18.4%27). Based on population projections prepared by the Newfoundland and Labrador Statistical Agency (medium scenario) in September 2006, the population of Economic Zone 18 - Avalon Gateway area is expected to continue to decline from 8,727 in 2001 to 6,419 by 2021.28 This population decline can also be seen in declining school enrolments since 1989.29

Data Source: NL Statistical Agency, Community Accounts, Demographic Accounts (Economic Zone 18) and Statistics Canada, 2006 Census

Some specific school enrolment patterns provide an even more dramatic example of population decline.30

Data Source: NL Statistical Agency, Community Accounts, Education Accounts (Economic Zone 18)

Data Source, NL Statistical Agency, Community Accounts, Education Accounts

Population aging is a key demographic trend for the Southern Avalon. This trend is expected to continue for both Economic Zone 20 (Irish Loop) and Economic Zone 18 (Avalon Gateway) where it is projected that the percent of the population aged 65 and older will grow significantly between 2006 and 2021. According to population projections prepared by the Department of Finance, Economics and Statistics Branch, Government of Newfoundland and Labrador, the 65 and older age group in the Southern Avalon (Economic Zones 18 and 20) will account for more than 30% of the entire population of the region by 2021.31 This aging of the population is important to understand as it will have an impact on the design and delivery of health and social services and programs. â&#x20AC;&#x153;We are a community of seniors.â&#x20AC;? Key Informant The population of persons aged 65 years and older is expected to increase in all areas of the Eastern Health region over the next twenty years. Population projections prepared by the Department of Finance, Economics and Statistics Branch, Government of Newfoundland and Labrador predict that the Southern Avalon will have a higher percentage of its population aged 65 and older by 2016 than any other area of Eastern Health.32

Data Source: Department of Finance, Economics and Statistics Branch, Government of NL

While the Southern Avalon is severely challenged by out-migration, efforts are being made to diversify the economy of the region to provide more job opportunities. Tourism is promoted as having economic potential; significant tourism investments have occurred in the past number of years. This is evident in the seasonal tour boat operations, interpretation centres, bed and breakfasts, coffee shops, theatre operations and other services for visitors that are appearing and attracting people from within and outside the province. In addition to tourism development, communities are attempting to diversify their economic base with local regional economic development efforts. Trepassey has made an effort, with some limited success, to attract a variety of small- and medium-sized businesses to the community. There is still employment activity related to the fishery with some plants providing seasonal work. Prices for raw material fluctuate from year to year - an increase or drop in the price paid for the various species of fish often means the difference between a viable or non-viable year for fishing enterprises. In 2006, prices for some fish species, such a crab, dropped significantly. A growing segment of the workforce in the Southern Avalon is transient - attracted to such western Canadian locales as Fort McMurray, Edmonton, Calgary and Iqaluit as well as work camps at various locations in Western Canada and the offshore industry in Newfoundland and Labrador. Some persons work a set number of weeks and months and then return to their home communities for a period of time. They may maintain their original home while they are away and leave family (often the wife and children) behind. In this case, the local economy receives a cash influx when people return, or from the money they send home. For others, the move away has been a semi-permanent one. They intend to stay out west until they retire and are maintaining their homes to keep as a retirement location. Yet another group of individuals and families has made the move a permanent one. In some cases, the younger generation re-locates and in subsequent years, the parents move to be closer to them.

Today some communities in the Southern Avalon (particularly those on the Irish Loop from Bay Bulls to Mobile, located adjacent to the St. John’s metropolitan area), are experiencing some growth and the future looks promising. These communities are regarded as offering a good quality of life, lower housing costs and adjacency to the services of a larger urban area. Other communities, more distant from the metropolitan area, are struggling to diversify their economy and provide jobs. It is here that out-migration is taking its greatest toll. During the focus groups and in discussions with key informants, the people of the Southern Avalon described themselves as tenacious and resilient, committed to their families and their communities. A strong Irish influence is still found in the area, and people are proud of their unique culture, song, dance and storytelling. Local theatre and cultural projects focus on retaining the stories and traditions of the area. The area has a magnificent natural beauty with many scenic and historical attractions (Cape St. Mary’s Ecological Reserve, Castle Hill, the East Coast Trail, Witless Bay Ecological Reserve, the Avalon Wilderness Reserve, The Colony of Avalon, Mistaken Point Ecological Reserve, the Cape Race lighthouse). Excellent salmon fishing rivers are found in the area and the landscape is truly unique - ranging from the barrens around Trepassey, the broad sweep of the ocean near St. Vincent’s; Holyrood Pond, a vast salt water lake, and the peaceful tranquility of the St. Mary’s Bay area. Throughout the entire region, the ocean is never far away.33

5.3. The Southern Avalon - The Future The future of the Avalon Gateway area of the Southern Avalon appears built on the anticipation of steady employment at the Voisey’s Bay Nickel Company iron ore processing plant - construction now planned to begin in Long Harbour in 2008.34 This company is predicting 1500 jobs during the construction phase and 500 permanent jobs when the plant is up and running. A demonstration plant is currently in operation in Argentia that employs 150 people. In addition to the anticipated jobs associated with heavy industry, Placentia will continue to be a service centre for the surrounding communities. Another development in the planning stage is a second oil refinery at the bottom of Placentia Bay, in Southern Head. The environmental assessment of this project is currently underway. Should the development proposal proceed, it would include a 300,000 barrels/day crude oil refinery and new marine facilities. Some skepticism was evident in key informant and focus group discussions that these developments would, in fact, go ahead. For many people in the area, the “roller-coaster” of uncertain economic expectations has been a difficult issue to contend with in the past ten years. The fishery will continue to play a role in many of the smaller communities along the Cape Shore and St. Mary’s Bay, and the Southern Shore, where seasonal work at fish plants will continue to be an important source of income for local people. Changes are anticipated in the fishing industry in the near future, and these changes, which may include rationalization, along with the fluctuating prices for fish, will have an important impact on the numbers and quality of jobs in the harvesting or processing sector. Growth in tourism for the entire Southern Avalon may boost local economies, as people are drawn to the uniqueness and beauty of the rural surroundings. The area is increasingly being regarded as a prime location for summer and/or retirement homes. A trend has been noted throughout the Southern Avalon region of retired persons purchasing homes and moving into the rural areas. Some are returning to the community of their birth after they retire. There are also anecdotes of homes being purchased as summer vacation sites by people from out of province or out of country who view the area as prime vacation property, with clean air, cooler summers relative to the mainland, and good property value for investment.

Public services such as the health centre in Placentia, the Placentia campus of the College of the North Atlantic and local elementary and secondary schools are regarded as key employers in the area - their importance to the local economy cannot be overstated. People are keen to maintain this infrastructure as the basis for local services and good jobs.

5.4. The Southern Avalon - Public Infrastructure The following table provides an overview of the public infrastructure in the Southern Avalon region.

6. An Overview of Key Health Status Indicators: Southern Avalon While this community health needs assessment analyzes the health-related needs of people and communities in the Southern Avalon from the multiple viewpoints of the determinants of health, an overview of the population’s health status can be gained by focusing on several key indicators. This section looks at four key indicators and compares results in the Southern Avalon (Economic Zone 18 - Avalon Gateway and Economic Zone 20 - Irish Loop) with the other areas of Eastern Health, the province of Newfoundland and Labrador, and the country. The four key indicators are: ◆ Community Well-Being Analysis (composite list of 14 indicators of community well-being) ◆ Mortality Indicators ◆ Chronic Conditions ◆ Self-Assessed Health Status

6.1. Community Well-Being Analysis Community Accounts Well-Being Indicator Analysis35 captures key data sets that provide an overview of social, economic and demographic facts that are influencing the health and well-being of people in the Southern Avalon. Table 6 illustrates key well-being indicators for the Southern Avalon - Economic Zone 18 (Avalon Gateway) and Economic Zone 20 (Irish Loop). For comparison purposes, the four other economic zones that fall within the Eastern Health boundaries are included: Economic Zone 15 (Discovery - the Bonavista Peninsula), Economic Zone 16 (Schooner - the Burin Peninsula), Economic Zone 17 (Mariner - Conception Bay North) and Economic Zone 19 (Capital Coast - the Northeast Avalon, including St. John’s). Table 6 highlights some significant issues having an impact on community health and well-being in the Southern Avalon including: ◆

Significant population decline for the entire region from 1996-2001. Census 2006 data indicates further population decline in the Southern Avalon.

◆

Economic Zone 18 - Avalon Gateway has significant economic and social challenges, including: ✧ Self-assessed health status (2001) - lowest in Eastern Health region. ✧ Low personal income per capita (2004), ranking 5/6 in Eastern Health region. ✧ Lower average couple family income (2004), ranking 4/6 in Eastern Health region. ✧ Low employment rate (2003), ranking 4/6 in Eastern Health region. ✧ Employment decline (-2.2% from 1998-2003) was the most significant in the Eastern Health region.

◆

Economic Zone 20 - Irish Loop is also experiencing economic and social challenges, but not to the same extent as Economic Zone 18 ✧ Self-assessed health status (2001) is highest in Eastern Health region. ✧ Personal income per capita (2004) and average family income per capita (2004) is second highest in the Eastern Health region. ✧ Social assistance incidence rates (2003) are the lowest in the Eastern Health region.

Data Source: Government of Newfoundland, NL Statistical Agency, Community Accounts, Well-Being Accounts The data sets have been updated to reflect most recent comparative information available for economic zones. * Per cent of respondents who rated their health as excellent, very good or good (Newfoundland Adult Health Survey 2001) ** Economic self-reliance ratio is a measure of dependency on government transfers (such as Employment Insurance, Old Age Security, income support, etc.). This column indicates the per cent of total personal income attributable to market sources (i.e. earned income).

6.2. Mortality Indicators What people die from (their cause of death) is an important health status indicator. Statistics Canadaâ&#x20AC;&#x2122;s annual mortality files classify causes of death into major headings called disease chapters. Figures 12 and 13 illustrate causes of death in the Southern Avalon. The figures show the proportion of all deaths in one year (2003) due to specific causes (grouped as disease chapters) for each area of the Southern Avalon. The figures illustrate that diseases of the circulatory system (cardiovascular disease) and cancer caused most of the deaths (63.9%) in the Avalon Gateway (Economic Zone 18) region and 54.5% of deaths in the Irish Loop region (Economic Zone 20).

Data Source: Newfoundland and Labrador Centre for Health Information, Statistics Canada Annual Mortality Tables, 2003

The preceding figures (12 and 13) describe deaths due to a specific cause (disease chapter) as a proportion of all deaths for each of the economic zones in the Southern Avalon. These mortality statistics can be compared to similar data for the entire Eastern Health Region and the province of Newfoundland and Labrador for 2003. Figure 14 compares cause of death (2003) by disease chapter in Economic Zone 18 (Avalon Gateway), Economic Zone 20 (Irish Loop), Eastern Health, and Newfoundland and Labrador.

Data Source: NLCHI: Mortality Statistics, Newfoundland and Labrador Regional Integrated Health Authorities 2000-2004

*Other includes the following causes: Infections, Diseases of the Blood, Mental and Behavioural Diseases, Diseases of the Eye or Ear, Diseases of the Digestive System, Diseases of the Musculoskeletal System, Diseases of the Genitourinary System, Congenital Malformations, Symptoms not otherwise classified. Deaths from external causes, such as accidents, are also included in this category.

Figure 14 illustrates that, for 2003, the proportion of deaths due to cancer in Avalon Gateway (Economic Zone 18) was slightly higher than the proportion of deaths due to cancer at the provincial level and notably higher than the proportion of deaths due to cancer in the Irish Loop. The proportion of deaths occurring from cancer in the Irish Loop was lower than the provincial figure and that of the Eastern Health region. Figure 14 also illustrates that, for 2003, the Southern Avalon had a slightly higher proportion (in comparison to the rest of the province) of deaths occurring from diseases of the nervous system and from endocrine, nutritional and metabolic diseases and a slightly lower proportion of deaths due to diseases of the circulatory system. In gathering this data, no analysis has been made to determine whether these differences are statistically and clinically significant.

6.3. Incidence of Chronic Conditions According to the Public Health Agency of Canada, chronic diseases are among the most costly and common health problems facing Canadians, but also the most preventable.36 Knowing the incidence of chronic conditions and diseases, such as hypertension, diabetes, arthritis, asthma, chronic mental conditions and cancer is another way we can better understand the health status of persons living in the Southern Avalon. However, there are challenges in capturing this information. Two methods that can be used in analyzing the extent and impact of chronic conditions and diseases include self-reported survey data and hospital discharge data. Both data sets have limitations. Survey data, such as the Newfoundland and Labrador Adult Health Survey (2001) and the Canadian Community Health Survey (2003) can provide us with a certain perspective on chronic conditions and disease. This perspective is limited in that the data is self-reported (the surveys were conducted by telephone). Self-reported data cannot always be verified by supporting empirical evidence (survey responses are dependent on the accuracy of the respondents recall and/or their personal beliefs). In addition, some Canadian Community Health Survey data for the Southern Avalon region is unavailable due to data suppression (a small sample size). This applies to data from Economic Zone 20 (Irish Loop). Self-reported data related to chronic conditions is displayed in Table 7 and Table 8. The data indicates that respondents in the Southern Avalon self-reported a slightly higher incidence of arthritis than was provincially self-reported, and a lower incidence of allergies.

Data source: Community Accounts: Newfoundland and Labrador Adult Health Survey, 2001

The data in Table 7 can be compared to self-reported diagnosed chronic conditions (Table 8) from the Canadian Community Health Survey of 2003. The respondents in this survey were persons aged 12 + who reported they have been diagnosed by a health professional with the particular chronic conditions. Only data from the Avalon Gateway area (Economic Zone 18) is available, due to the small sample size in Economic Zone 20 (Irish Loop).

Table 8 illustrates similar findings for the Avalon Gateway (Economic Zone 18) area (self-reported diagnosed chronic conditions), when compared to provincial data for the same survey.

Data source: Community Accounts: Canadian Community Health Survey 2003; Health Status of Individuals * Data is suppressed due to confidentiality issues (small sample). ** Confidence intervals, for 95% confidence level, are noted in italics. A confidence interval is a statistical range with a specified probability that a given parameter is within the range. As this survey included only a small sample of the population in Avalon Gateway, the confidence interval is large (results could vary + or - by 10.5%). *** In the 2005 Canadian Community Health Survey, the rate of diabetes self-reported by the population aged 12 and older in NL is 6.8%; in Canada, the rate is 4.9 %.37

Hospital discharge data can provide insight into the impact of chronic disease in the Southern Avalon. Hospital discharges are grouped into categories called case mix groups. A case mix group is â&#x20AC;&#x153;...a method of grouping patients into clusters based on clinical diagnoses, procedures and resource utilization.â&#x20AC;?38 Discharge data for the past three years (2003-2006) from the Placentia Health Centre, St. Johnâ&#x20AC;&#x2122;s adult hospitals, the Janeway Child Health Centre and Carbonear General Hospital provides details about hospitalization for residents of the Southern Avalon due to chronic disease. Table 9 lists the top ten chronic disease case mix groups represented in hospital discharge data (2003-2006) for patients from the Southern Avalon.

Data source: CIHI Portal

Cancer is categorized as a chronic disease by the Public Health Agency of Canada.39 The Newfoundland Cancer Registry data indicates that 289 new cancers were diagnosed in residents of the Southern Avalon in the period 2003-2005. Based on the 2001 census population of 17,300, this indicates that 1.67% of the population were diagnosed with cancer over a three-year period (2003-2005). For the Burin Peninsula (population 23,710 - 2001 census) there were 413 cancers diagnosed for the same period (a rate of 1.74% of population over a three-year period). Further geographic breakdown of this data for the sub-regions of the Southern Avalon (Economic Zone 18 - Avalon Gateway and Economic Zone 20 Irish Loop) was unavailable. No further analysis of this data was conducted. In the telephone survey carried out for the Southern Avalon Community Health Needs Assessment, 29% of respondents identified chronic illness as a major problem in their communities; 48% identified cancer as a major problem. Work is continuing on a comprehensive integrated and collaborative cancer control strategy for Newfoundland and Labrador. The purpose of this strategy is to reduce the incidence and impact of cancer in the province and to improve access to all aspects of cancer control in Newfoundland and Labrador.40

6.4. Self-Assessed Health Status One of the key indicators of health status is a person’s own perception of their health. The following figures and table illustrate how people feel about their physical and mental health in the Southern Avalon (Avalon Gateway - Economic Zone 18 and Irish Loop - Economic Zone 20). Figure 15 compares the data on self-assessed health status for the Southern Avalon region to provincial results (NL Adult Health Survey, 2001). It indicates that a slightly higher percentage of people in the Southern Avalon assessed their health as excellent or very good, compared to the province as a whole; residents in Avalon Gateway had higher self-assessments of fair or poor health and lower self-assessments of good health compared to the Irish Loop area and the province. The data in Table 10 compares results for the Southern Avalon, the province of Newfoundland and Labrador and Canada from the Canadian Community Health Survey (2003) where respondents rated their health and mental health status. Data is unavailable for Economic Zone 20 (Irish Loop), Data source: Community Accounts: Newfoundland due to a small sample size. In Economic Zone 18 and Labrador Adult Health Survey, 2001 (Avalon Gateway), fewer respondents self-rated their physical and mental health as “excellent” compared to the province and the country, however a higher number of respondents rated their mental health as “very good” and “good” than did respondents in Newfoundland and Labrador and Canada. (“Very Good” ratings of physical health in Economic Zone 18 - Avalon Gateway were similar to provincial ratings; “good” ratings of physical health were higher than provincial or national ratings.) “Fair” and “Poor” ratings of physical and mental health were similar to provincial and national ratings. It is important to note that the confidence intervals for Economic Zone 18 (Avalon Gateway) data are high. This is due to the small sample size.

Table 10: 2003 Canadian Community Health Survey: Self-Assessed Health/Mental Health Status (Respondents Aged 12 Years and Older) AVALON GATEWAY (Economic Zone 18)

IRISH LOOP (Economic Zone 20)

PROVINCE OF NL

CANADA

Health

Mental Health

Health

Mental Health

Health

Mental Health

Health

Mental Health

Excellent

8.4% (6.8%)**

31.8% (11.6%)**

21.1% (1.3%)

40.0% (1.6%)

22.3% (0.2%)

38.6% (0.3%)

Very Good

44.4% (12.2%)

40.0% (12.2%)

45.4% (1.6%)

36.5% (1.5%)

36.3% (0.3%)

35.1% (0.3%)

Good

35.7% (11.8%)

24.9% (10.8%)

22.5% (1.3%)

20.3% (1.3%)

30.1% (0.3%)

21.7% (0.2%)

Fair

6.2% (5.9%)

2.7% (4.1%)

7.5% (0.8%)

2.6% (0.5%)

2.6% (0.2%)

3.8% (0.1%)

Poor

5.4% (5.6%)

0.6% (1.9%)

3.4% (0.6%)

0.6% (0.2%)

0.6% (0.1%)

0.8%(’)

Data source: Community Accounts: Canadian Community Health Survey 2003 * Data suppressed due to confidentiality issues (small sample). ** Confidence intervals, for 95% confidence level, noted in italics.

During the telephone survey of a random sample of Southern Avalon residents, respondents were asked to rate their own physical and mental health. The Southern Avalon telephone survey data indicates that approximately 29% of respondents rated their physical health as “fair” or “poor” (21% rated physical health as “fair”; 8% as “poor”). Seventy-one (71%) of telephone respondents rated their physical health as good, very good or excellent (28% rated physical health as “good”; 34% rated it as “very good” and 9% rated it as “excellent”). Telephone survey data indicates a lower self-rating for physical health than the provincial rates on the 2003 Canadian Community Health Survey. (In this survey, 89% of respondents viewed their physical health as “excellent, very good or good”). For Southern Avalon telephone survey respondents, 10% rated their mental health as “fair” or “poor” (8% as “fair”; 2% as “poor”) while 90% viewed their mental health as “excellent”, “good” or “very good”). This compares to provincial data from the 2003 Canadian Community Health Survey where approximately 3% of respondents viewed their mental health as “fair” or “poor” and 97% viewed it as “excellent, very good or good”.

7. Determinants of Health (Health Services) This community health needs assessment examines the health status of the people and communities of the Southern Avalon by viewing community health needs through the lens of the determinants of health. Section 7 focuses on the Health Services determinant and associated findings; section 8 focuses on the remaining ten determinants of health and associated findings (Income and Social Status, Social Support Networks, Healthy Child Development, Education, Social Environments, Physical Environments, Personal Health Practices and Coping Skills, Biology and Genetic Endowment, and Gender and Culture). Health services, particularly those services designed to maintain and promote health, to prevent disease and to restore health and function, contribute to population health. The health services continuum of care also includes treatment and secondary prevention. Eastern Health is responsible for the continuum of health services on the Southern Avalon and categorizes its services within four lines of business41 (key services). These lines of business are: Promote Health and Well-Being Provide Supportive Care ◆ Treat Illness and Injury ◆ Advance Knowledge ◆ ◆

In the Southern Avalon, these lines of business are delivered from worksites in Witless Bay, Ferryland, Trepassey, St. Mary’s, Mount Carmel, St. Joseph’s, St. Bride’s, the Placentia Health Centre and the Placentia Court House. In some instances, Eastern Health staff based at one site will also travel to additional sites in the region to deliver the service (or, in some cases, make home visits). In other instances, the staff located at Eastern Health sites outside the Southern Avalon region (such as the Holyrood, Whitbourne, Harbour Grace and St. John’s offices of Eastern Health) will travel to the Southern Avalon region upon receiving a referral for service. In still other instances, services are offered from a site outside the Southern Avalon region and clients must travel outside the region to access the services. An example of this is when a client from the Irish Loop requires high level long term care and is admitted to a long term care facility in St. John’s, or when a client from the Placentia/Cape Shore area requires addictions counselling and must travel to Whitbourne for service. See Appendix L for a geographic overview of health services provided from various sites in the Southern Avalon region. See Appendix M for an infrastructure assessment of facilities on the Southern Avalon.

7.1. Promote Health and Well-Being 7.1.1. Overview of Services Eastern Health’s services include those designed to promote and protect population health and help prevent disease and injury. Three main categories of service are provided under this line of business (Health Protection-Disease Prevention; Health Promotion; Child Protection)

7.1.2. Findings Health Protection and Disease Prevention Protecting health and preventing disease are critical to achieving Eastern Healthâ&#x20AC;&#x2122;s vision of Healthy People, Healthy Communities. This work is accomplished through a variety of methods, including child immunization, surveillance and management of outbreaks, monitoring of environmental health, coordination of all-hazards emergency preparedness and licensing and monitoring of child care spaces to ensure standards are met. Community health nurses, communicable disease surveillance staff and environmental health staff play a key role in protecting health and preventing disease. In the Southern Avalon region there is some variation in the way service is organized and delivered. Some community health nurses provide both public health and continuing care services; others focus specifically on either public health or continuing care. Staff dedicated to communicable disease surveillance and environmental health are located in Holyrood and St. Johnâ&#x20AC;&#x2122;s and liaise regularly with frontline staff based at worksites on the Southern Avalon.

Specific findings related to health protection and disease prevention - Southern Avalon: Two-year immunization rates (the per cent of two-year-old children with all immunizations complete) for the region for the past three years (2003-2006) are at or near 100%. School entry immunization rates (the per cent of school entry children with immunization status complete) for the region for the past three years (2003-2006) are at or near 100%. Communicable disease outbreaks (should they occur) are managed in conjunction with the communicable disease surveillance staff in Holyrood and St. Johnâ&#x20AC;&#x2122;s. There have not been any communicable disease outbreaks in the Southern Avalon region for the past three years. Environmental health issues are managed from the Holyrood and St. Johnâ&#x20AC;&#x2122;s offices. Over the past three years, no food or water borne outbreaks have occurred in the Southern Avalon region (although food preparation by not-for-profit organizations continues to require monitoring). The main ongoing environmental health issue in the area in the past three years relates to water quality. As of the writing of this report, 14 communities in the Southern Avalon are advised to boil their water. The Eastern Regional Water Committee has been set up by the provincial government to assist communities with developing permanent solutions in improving their water. Eastern Health takes an active role on this committee. Licensing of child care spaces is handled by staff in St. Johnâ&#x20AC;&#x2122;s and Harbour Grace. There are no licensed daycare spaces for the Irish Loop area (Economic Zone 20) of the Southern Avalon, however, there are two individual family child care licenses (with the ability to accommodate 12 children). There are 16 licensed child care spaces in the Avalon Gateway area (Economic Zone 18) of the Southern Avalon (in the town of Placentia). Eastern Health All-Hazards Advisory Committee has been established to ensure regional consistency for all Eastern Health sites and services. The focus will be on ensuring a universal framework for maintaining and/or restoring Eastern Health services in the event of an emergency, and partnering with the provincial Emergency Measures Organization (EMO) and municipalities as they develop and implement their emergency plans. Placentia Health Centre has an all-hazards emergency plan in place and is linked with the municipal emergency plan. Health Promotion Health promotion is a comprehensive range of population health and community development programs aimed at enabling and fostering individuals, families and communities to take control of and improve their health. This is accomplished through a variety of strategies including information sharing, community mobilization and capacity building, group facilitation, advocacy, the provision of resource materials and the improvement of health status in our communities.42 Specific findings related to health promotion - Southern Avalon: The importance of health promotion: Key informants and focus group participants were unanimous in expressing the view that health promotion is essential in contributing to improved health outcomes. There was consensus that promoting health and wellness should be a priority for the health system as it will reduce future health costs associated with treating illness. They recommended that Eastern Health be inclusive and creative in its approach to health promotion, making a special effort to connect with people who have lower literacy levels and those

struggling with social and economic challenges. These findings reinforce the provincial focus on health promotion described in the Newfoundland and Labrador Wellness Plan (Achieving Health and Wellness: Provincial Wellness lan for Newfoundland and Labrador 2006-2008).43 Health promotion must be supported throughout life - but with a special focus on the early years: Good habits begin early; key informants stressed the importance of focusing on health promotion with children and youth. They spoke positively of the benefits of the Family Resource Centres’ programs and the role these centres play in health promotion. Family Resource Centre programs are offered in Placentia (4 days/week), Mt. Carmel (4 hours/week) and St. Bride’s (4 hours/week) as well as Ferryland (3 days/week) and Bay Bulls (3 days/week). Family Resource Centres operate independently from Eastern Health with their own board of directors (with an Eastern Health representative) and staff. Key informants and focus group participants stressed that Eastern Health must continue to strengthen our partnership with Family Resource Centres, schools and communities and take every opportunity to promote health and wellness early in life. Actively partner with the school system to encourage health and wellness: Key informants and focus group participants were enthusiastic about the activities happening at schools to promote health and wellness. They spoke positively of the school health teams and their efforts, the shift to healthier food choices as the School Food Guidelines are implemented, and events such as the Health Commotion days (Fall 2006) that were rated a success. They encouraged continued partnering between Eastern Health and the school system to promote health and wellness. Eastern Health currently has two temporary School Health Coordinator positions working with schools on health promotion activities. Just recently Eastern Health initiated a Health Promoting Schools Initiative where schools can apply for a grant up to a maximum of $300 to support them in developing and delivering initiatives that promote health within their school community and complement what is being taught in the classroom. Promote self-care initiatives and targeted screening programs for adults: Eastern Health was urged to continue its efforts to encourage self-care and promote participation of men and women in screening activities such as the Well Women and Well Men clinics. The focus on rural health such as the Rural Women’s Health Days (organized by the Placentia Primary Health Care Renewal Initiative) was mentioned as an example of a positive health promotion activity. These sessions have been very well received and people want more of such activities and events in the Southern Avalon. Mental health promotion and health promotion for seniors were mentioned by key informants and focus group participants as areas that are often overlooked, and Eastern Health was encouraged to ensure this focus was included in their promotion planning and activity. Engage and support communities/community groups in developing community-based health programming. Key informants and focus group participants identified a need to listen to, work with and support communities as they develop their own ideas and approaches to health promotion. They noted that working with and through communities is the most effective way to engage people in health promotion. Moving for Health groups (six groups have been established in the Avalon Gateway, Economic Zone 18 of the Southern Avalon) and the work of the Primary Health Care Renewal Initiative (Placentia and St. Mary’s), were mentioned as examples of how to work positively with communities in promoting health. In addition to promoting expansion of community-based health programs such as Moving for Health groups, Eastern Health was encouraged to build the capacity of its staff in working with communities.

Community engagement and support can be provided in many ways. It might include assistance in the project development phase, project funding (it was noted that small amounts of money can go a long way) and help in evaluating effectiveness of programs. Some community groups, supported by small financial grants from a variety of sources such as the Wellness Coalitions, have delivered creative health promotion activities at the community level. Southern Avalon groups that have received Wellness Coalition grants include the Trepassey 50+ Club, Irish Loop 50+ Association, Branch Recreation Committee (Well Teen Club), Placentia-Cape Shore Community Advisory Committee (Community Kitchen) and Gaskiers-Point La Haye Recreation Program. Provincial grants have been awarded to Tramore Productions in Cuslett for a summer drama incorporating wellness concepts. Key informants and focus group participants strongly encouraged more of this community-based approach. Help communities address challenges in promoting health on the Southern Avalon: Key informants and focus group participants identified some challenges in promoting health on the Southern Avalon. In communities where the population has declined, some recreational activities are no longer viable.

“We don’t have ball hockey here this year. We couldn’t get 10 males between the ages of 17-35 - they’re just not in this community any more.” - Key Informant

A network of walking trails is available in some communities (notably the East Coast Trail on the Southern Shore, the Argentia Backlands Trail system and the seawall walkway in Placentia). While these trails are being promoted and used by local residents (as well as tourists), they aren’t easy to use during the winter season, and are inaccessible to many seniors. Some communities have ice arenas (Southern Shore arena, Trepassey arena, Placentia arena) and a few communities have gyms available to the public (the P4 Centre in Dunville, the Father Val Power Centre in Riverhead). These alternative spaces are limited and there is a cost associated with using them (although minimal at the P4 centre). Very often, the only alternate for exercise in many areas of the Southern Avalon is to take a walk along the side of the highway, and this can be unsafe at any time of the year, particularly in poor weather or after dark. A common theme that was heard during key informant and focus group meetings was the inability to access space (and/or the lack of any space) where people of varying ages can come together at any time of year and engage in activities to keep healthy, such as walking, exercise programs, and sports. In the Southern Avalon, like most of rural Newfoundland and Labrador, the school is one of the few public spaces in the community. In some communities, public access to schools is difficult or impossible to obtain due to liability issues faced by school boards when they provide space after hours to community groups. Some key informants and focus group participants wondered whether Eastern Health could help them access community infrastructure to support wellness initiatives.

Focused investments in supporting health promotion are required: In the opinion of many informants and focus group participants, alternative mass marketing approaches to health promotion should be explored. While Eastern Health’s Our Health magazine is well-received, many informants suggested using television as a medium to get the health promotion message out to a larger audience and make an impact on people who might otherwise not respond to written materials. Another suggestion was to be creative in the scheduling of health promotion activities to better meet the needs of participants. In the Southern Avalon, Eastern Health staff who work at the front line incorporate health promotion as a component of their daily work. They need to be supported in this role and their capacity for working in partnership with communities must be strengthened. Some dedicated health promotion staff have this focus as their primary role; these staff now work together as a single Health Promotion Department and take a lead in particular areas. They include School Health Coordinators, Parent and Child Health Coordinators, Health Educators, Health and Wellness Consultants, Regional Nutritionists and Lactation Consultants. These consultants work directly with community groups or support Eastern Health’s front line staff in their health promotion activities. Community Success Stories - Health Promotion: The Tramore Theatre Group in Cuslett is an example of innovative community approaches to health promotion. In the summer of 2006, with funding from the provincial Wellness Grants program, the troupe launched their Arts for Health initiative, producing a play that incorporated the themes of healthy lifestyle choices and wellness. The play was wellreceived by audiences and generated a lot of positive comments. The drama troupe integrated the wellness theme into their rehearsals, beginning each one with a brisk hour-long walk around their community. The Tramore Theatre Troupe members lived the message they were promoting - and have continued to support each other in healthy living, beyond the summer theatre season. The 50+ Seniors Group in Trepassey are constantly looking for ways to promote health and wellness with seniors in their area. In addition to offering ongoing programs such as “Walk Away the Pounds”, and “Tai Chi Chih”, they are sensitive to the changing needs of seniors. In December 2006, the group decided to focus on mental health promotion. They were concerned with the increasing numbers of seniors living alone in the community without family support (sons, daughters and grandchildren having relocated to the mainland for employment). These seniors were experiencing loneliness, and club members feared that this loneliness might be deepening into depression for some. The club responded by organizing a day of events focused on promoting mental health. The day’s activities included guest speakers, discussion groups, socializing and a meal - the key was to bring seniors together and discuss openly some of the things that were having an impact on their mental health. “We need to plan activities to keep our spirits up. Things around here could really get you down if you let them. We have a responsibility to our community to help.” - Key Informant The energy and determination of the Trepassey 50+ Seniors Group is a great example of community commitment in action.Another example of creative partnering with schools was noted at Mobile School, where student nurses were able to link with the school while they were learning about health promotion in their nursing program. They developed a health promotion project, talking first to students to identify the health-related issues of concern to them and developing and delivering presentations on these issues. Students developed a good rapport with the nursing students, responded very positively to them, and were pleased with the sessions they attended.

Child Protection There are a range of services and interventions offered to vulnerable children, youth and their families. Under the Child, Youth and Family Services Act, Eastern Health is mandated to respond to referrals of child maltreatment, assess risks to children and youth and provide protective intervention services. These services include the provision of foster homes, supervision of youth on probation and those in protective custody. Specific findings related to Child Protection - Southern Avalon Demographics of the Southern Avalon are changing. This means that there are fewer and fewer children and youth as a per cent of the total population; this is reflected in the relatively low numbers of children receiving services or interventions in this region. Referrals to Child, Youth and Family Services have been stable in some areas of the Southern Avalon for the past three years, but are increasing in other areas. (See Table 12) Foster care has been provided to a relatively small number of children in the Southern Avalon over the past three years. Table 13 describes the number of foster homes and the number of children in care over the 2004-2006 period. Although the table indicates there are adequate numbers of foster families based on numbers of children requiring care, Eastern Health staff and some key informants noted that there was difficulty in recruiting and retaining foster families. Long term protection cases (number of families with active protective intervention files) remain somewhat stable for the Southern Avalon, as described in Table 14. Numbers of youth on probation and in custody are declining in the Southern Avalon region as described in Table 15.

*Significant other caregivers are ones approved for a particular child or children based on their significant relationship with the child or children.

7.1.3. Recommendations 1. Ensure Eastern Health’s health promotion plan (expected release date Fall 2007) includes initiatives that address the particular needs of rural areas. The following specific areas for health promotion/health promotion delivery have been identified: a. Seniors’ health promotion (in light of the significant aging of the population). b. Mental health promotion (noting the need for community support/partnerships and the role of all members of the rural primary health care team). c. Pre-school and school health promotion strategies. d. Dental (oral) health promotion (in light of findings related to poor oral health). e. Accessible, affordable community options for community-based health programming (such as Moving for Health programs). f. Innovative methods of communicating health promotion messages. 2. Identify opportunities to expand the School Health Team model to the entire Southern Avalon area of Eastern Health. 3. Advocate to strengthen Eastern Health’s health promotion capacity/linkage with the school system. 4. Establish a community grants fund, administered through Eastern Health, to support community-initiated projects at the community level. 5. Explore the possibility of expanding the Celebrating Rural Health initiative to two events in the Southern Avalon area (Irish Loop and Avalon Gateway), within two years of the release of this report. 6. Advocate with the Eastern School District and Department of Education to increase community groups’ ability to access schools for health-related activities and initiatives.

7.2. Provide Supportive Care 7.2.1. Overview of Services Eastern Health provides community-based support and continuing care, residential care options, home support and nursing home care for individuals with assessed needs. These services are means-tested and criteria-based.

Table 16: Provide Supportive Care - Southern Avalon Delivery LINE OF BUSINESS CATEGORY Individual, Family and Community Supportive Services including: • services for alternate residential options • home support • assessment and placement services • behavioural supports • palliative care • neglected adults referrals

SOUTHERN AVALON DELIVERY • Community Supports social workers working from Ferryland, St. Joseph’s and Placentia,

facilitate referrals for services (alternate residential options, home support). • • • • • •

day support foster care supportive family services community behavioural services direct home service adoptions

Short term adult residential care including:

• Behaviour management intervention, child management intervention services, adoptions,

foster care services are available on referral from Whitbourne, Holyrood and St. John’s. • Community health nurses provide continuing care follow-up and limited community-based palliative care. • Assessment and placement services are provided from St. John’s and Whitbourne.

• One respite bed located at Placentia Health Centre.

• respite care

Long term adult residential care including: • • • •

provision of long term care, monitoring and licensing of personal care homes alternative family care placement management of cottages

• Seventy-five long term care beds at Lion’s Manor, Placentia (co-located at Placentia Health Centre). • Some long term care placements in St. John’s long term care facilities. • Personal care home monitoring provided from St. John’s and Whitbourne offices.

Multiple personal care homes available in region. • Alternate family care placement through social work services in Holyrood and St. John’s,

supported by social workers in Southern Avalon region. • Forty seniors cottages (managed by Eastern Health, owned by NL Housing) in Placentia.

7.2.2. Findings The key theme that emerged for the Southern Avalon in relation to providing supportive care is: An aging population will require additional supportive care options: Key informants, focus group participants, and written submissions all stressed the significant health-related needs of an aging population. Demographic and migration data point to a dramatic population shift in communities on the Southern Avalon, where older persons are now a significant percent of the population. Out-migration was identified by telephone survey respondents as the most serious issue facing the communities in the region - and those leaving the communities of the Southern Avalon tend to be of working age. Seniors are remaining in their communities, sometimes without immediate family to provide supportive care. These issues are similar to those identified in a background discussion document prepared by the Division of Aging and Seniors, Newfoundland and Labrador Department of Health and Community Services, for consultations on developing a provincial Seniors Framework. Key informants and focus group participants identified home support, supportive housing options and long term care issues as particular needs of the aging population on the Southern Avalon.

Home support issues identified by key informants/focus groups: ◆ Accessing home support can be a complicated and intimidating process for some applicants. They often require assistance from Eastern Health staff to move through the necessary steps, including the financial assessment. ◆

Frontline staff identified the significant time that is required to assist people interested in accessing home support work their way through the process.

◆

Some clients may be discouraged from accessing the home support service because they are required to contribute financially, based on their financial assessment; access to subsidies requires very low income levels.

◆

Some clients, perhaps because of the challenges they experience in trying to access the home support program, may “put off ” looking for assistance until their needs are so great they find it very difficult to function on their own. At this point, their requirements for support may be such that they can no longer stay in their own home and may need personal care home or long term care admission.

◆

Some clients are finding it difficult to obtain consistent home support workers. Various reasons were suggested for this difficulty including the unattractive hourly wage, frequent split shifts, lack of training for the job and a smaller population base from which to draw workers.

Telephone survey respondents who reported using home support services were very satisfied (51%), somewhat satisfied (13%) neutral (16%) or somewhat dissatisfied (3%). Seventeen per cent (17%) of respondents were very dissatisfied. Two (of 14 respondents) indicated they had difficulties in arranging home support due to difficulties in finding a care-giver and too much “red tape”. Table 17 shows home support utilization and costs for the Southern Avalon area (2004-2007 to date). Detailed information on the Southern Avalon was difficult to extract from existing databases. In some cases, only the most current year’s information is available.

Supportive Housing options for seniors on the Southern Avalon include some community-managed apartment units in Trepassey (12 units - four persons on wait list), St. Joseph’s (8 units - no wait list) and St. Brides (14 units - no wait list). Forty seniors’ cottages (30 one-bedroom and 10 two-bedroom), managed by Eastern Health, are available in Placentia. In January 2007 there were 15 individuals and 8 couples on the waitlist for these cottages. Priority for admission to the cottages is based on an assessment that considers income, present living conditions, and physical illness/disability with the weight of the assessment placed on financial status. Key informants and focus group participants identified other supportive housing-related needs for seniors, especially timely access to the provincial home repair program (seniors want to stay in their own homes if at all possible). “Some seniors in this area depend on the visit of my delivery person to get some help with small home repair jobs. They haven’t got any family around here any more to do the little things for them, let alone the bigger house repairs.” - Key Informant The provincial home repair program, delivered by the Newfoundland and Labrador Housing Corporation, is challenged to meet current demands for service; there is a significant wait list. (Newfoundland and Labrador Housing estimates there are currently approximately 168 persons from the Southern Avalon region approved and waiting to access the home repair program). This issue of access to home repairs can sometimes contribute to difficulties in hospital discharge planning, as some individuals are unable to return home if the environment is unsuitable. Key informants and focus group participants identified the need for Eastern Health and Newfoundland and Labrador Housing to develop a strong partnership related to supportive housing issues. Personal care homes provide housing and care for persons no longer able to live independently in their own homes and who require more than home support. Individuals assessed as requiring level one or level two care are eligible for placement in personal care homes; those requiring higher levels of care are eligible for placement in a nursing home. There are eleven (11) licensed personal care homes in the Southern Avalon region with 217 beds. One hundred and fiftysix (156) of these beds are subsidized. Applicants are also able to apply for a portable subsidy (a waitlist for portable subsidies may occur). Occupancy rates have declined for some of these personal care homes in the past three years. As of February 2007, three of the eleven personal care homes on the Southern Avalon had occupancy rates at 50% or lower. Because of low occupancy rates, wait times to access a personal care home bed are generally not an issue. In the telephone survey carried out as part of this community health needs assessment, 43% of respondents who reported having admitted a member of their family to a personal care home in the past year were very satisfied with the personal care home, 40% were somewhat satisfied, 9% were neither satisfied nor dissatisfied, 3% were somewhat satisfied and 5% were very dissatisfied. Higher level long term care (nursing home care) is available through the Lion’s Manor (75 beds) at the Placentia Health Centre and/or in a nursing home in the St. John’s area. Focus group participants and key informants stressed that individual and family preference was to be placed in a facility closest to their home community. There are no options for high level nursing home care in the Irish Loop (Economic Zone 20) area. Assessment and placement for long term care is through the single entry system managed by Eastern Health. The occupancy rates and wait list for Lion’s Manor for the past three years (2003-2006) are noted in Table 18.

A perception encountered during focus group and key informant discussions was that many of the acute care beds at the Placentia Health Centre were being occupied by patients (often seniors) who lack the necessary supports to return home and/or who are waiting for admission to a personal care home bed or long term care bed at Lion’s Manor. A review of discharge data for the Placentia Health Centre for the past three years (2003-2006 - see Table 19) indicates that three of the top five categories of care (case mix groups) at the Placentia Health Centre have an average of over 10 days length of stay (LOS). The coding of two of these case mix groups (Other Specified Aftercare and Other Factors Requiring Hospitalization) was further analyzed to determine what particular cases were contained within these categories. All cases coded Other Specified Aftercare (2003-2006) were patients receiving palliative care. Cases coded Other Factors Causing Hospitalization included patients convalescing following various other treatments (including 11 cases of convalescence following treatment of fracture), 5 cases of patients needing assistance at home, and 2 cases of patients awaiting admission to another facility. It is important to note that since May 2006 a First Available Option policy has been put in place to ensure that clients in need of long term care receive the most appropriate care based on their assessed need. The implications of this policy would not be noted in the 2003-2006 data examined for this needs assessment.

Data source: Canadian Institute of Health Information portal * Case Mix Group: CIHI applies a grouping methodology to put like cases using like resources into one group called a Case Mix Group. This grouping is driven by the most responsible diagnosis. ** Length of stay (LOS) refers to the number of days a patient stays in hospital.

Residents in the Irish Loop (Economic Zone 20) must go to St. John’s area nursing homes to access higher levels of long term care. Based on information available at the time of the needs assessment, it appears that admissions from the Southern Avalon to nursing homes in the St. John’s area have risen slightly over the past two years.

As of April 17, 2007, eight residents from the Southern Avalon were assessed for placement and waiting for admission to a St. Johnâ&#x20AC;&#x2122;s area nursing home. Telephone respondents reported no difficulties in admitting a family member to a personal care home or a nursing home. In terms of satisfaction with service in nursing homes, 35% were very satisfied with service, 36% were somewhat satisfied, 14% were neither satisfied nor dissatisfied, 7% were somewhat dissatisfied and 8% were very dissatisfied. Some focus group discussions centred on the desire of families and clients to receive care as close to home as possible if they required admission to a personal care home or nursing home. This appears to be a particular issue the farther away from St. Johnâ&#x20AC;&#x2122;s one lives - it emerged in discussions in Trepassey and Placentia areas. Increased community-based palliative care was identified as a need by some key informants. Eastern Health is in the process of responding to this issue by increasing the amount of home care available to persons wanting to receive palliative care in the community. Need for home care after hospital discharge was also identified as an issue. A pilot program is being initiated in several areas of Eastern Health that will provide limited home care post-discharge. Social support for seniors was identified as one of the most important needs by many key informants and focus group participants. This need was noted as an especially important concern for isolated seniors - those who may be living alone, with few daily contacts. Some suggestions included community initiatives to bring seniors together in a social setting, combining a social outing with a health promotion activity, speaker or event.

Community Success Stories - Social Support for Seniors: The community of Branch on the Cape Shore has started a program called The Singing Kitchen, focused on bringing the community together with a special goal of helping to meet the social and nutritional needs of seniors. Meals are prepared and available at a minimal cost once a week in the community centre. Seniors and other community members are encouraged to come and visit with each other, enjoy each otherâ&#x20AC;&#x2122;s company and have a good meal as well.

Supportive housing for persons requiring alternate family care-giving arrangements: Eastern Health meets the needs of individuals requiring alternate family caregivers (often these are individuals with a developmental disability) by recruiting alternative family caregivers and matching them with clients requiring care. It is challenging to recruit families to take on this responsibility; there are few incentives (board and lodging rates are $1098/month). Table 21 illustrates the number of individuals placed in alternative family care-giving arrangements in the past three years and the number of alternative family care homes in the region. Providing respite care arrangements is one of the difficulties in providing this service.

7.2.3. Recommendations 1. Convey findings of Southern Avalon Community Health Needs Assessment to Newfoundland and Labrador Housing Corporation (NLHC). 2. Initiate liaison committee between NLHC and Eastern Health to promote effective partnerships and improved supportive housing programs, such as the home repair program. 3. Conduct a comprehensive analysis of future long term care bed needs in the Placentia area (Lionâ&#x20AC;&#x2122;s Manor), in light of significant aging of population. 4. Standardize home support policies and procedures across Eastern Health region to ensure clients receive the same information and level of service. 5. Advocate with the Department of Health and Community Services for changes to the home support program that would help streamline the financial assessment process and increase access to low level supports.

7.3. Treat Illness and Injury 7.3.1.Overview of Services Eastern Health investigates, treats, rehabilitates and cares for individuals with illness or injury.

In addition to the primary health care service provided by Eastern Health staff, there are other private health care providers in the area (general practitioners, dentists, pharmacists, and ambulance operators). The Department of Health and Community Services also provides a toll-free Tele-health phone service that is available province-wide.

7.3.2. Findings Physician Services Participants in key informant interviews and focus groups stressed the importance of primary health care service in the Southern Avalon. The overall focus of their comments was that a consistent dependable primary health care service, built around a strong team of primary health care providers, and preferably with stable family physicians, is essential. As of the time of the data collection for the needs assessment, there was a full complement of salaried general practitioners at Eastern Health facilities (Shamrock Health Clinic in Ferryland, St. Mary’s/Mt. Carmel Health Clinic and Placentia Health Centre) and long-serving fee-for-service physicians providing primary care in Bay Bulls, Trepassey and Placentia. Key informants and focus group participants were pleased that all physician positions were filled at the time of the needs assessment. They noted the relative longevity of fee-for-service general practitioners in some areas of the Southern Avalon (Bay Bulls, Trepassey and Placentia) and felt this was a strength. However, many key informants and focus group participants expressed concern about the future if or when the long-serving fee-for-service general practitioners chose to retire or decided to reduce their practices.

“If Dr. McGarry were to leave Trepassey, it would be devastating. When Dr. McGarry goes, Trepassey goes.” - Focus Group Participant “If Dr. McGarry leaves, I’ll have to leave Trepassey too.” - From a senior in Trepassey

Several key informants and focus group participants raised concerns about physician turnover and the subsequent lack of continuity in physician care. This concern was particularly strong in the St. Mary’s/Mt. Carmel and Placentia areas. “Without a doubt, the most important requirement of the St. Mary’s Bay area is the knowledge that there will be stability and dependability of health care services…” - Written submission A history of gaps in coverage or multiple salaried and locum physicians providing service at the Placentia Health Centre, the St. Mary’s/Mt. Carmel Clinic and, to a lesser extent at the Shamrock Clinic in Ferryland, has caused some people to decide to travel out of their area for general practitioner services. General practitioners in Bay Bulls, Trepassey, St. John’s, Placentia, Holyrood or Conception Bay South are viewed as providing a more stable physician service. This trend is evident in data from the Southern Avalon Telephone Survey. Respondents were asked in which community their family doctor was located. It is evident from Table 25 that many are choosing to travel out of their area for physician services.

The following tables (Table 26 - Table 28) demonstrate the challenges that have been encountered in providing consistent general practitioner service at the Placentia Health Centre, the St. Mary’s/Mt. Carmel Clinic and the Shamrock Clinic in Ferryland.

* Full complement is four salaried physicians ** Note: During periods when physician positions were vacant, coverage was provided by visiting physicians (locums)

At the time of the needs assessment, a full complement of salaried physicians was in place at the Placentia Health Centre. Table 27 describes general practitioner coverage (solo physician) at St. Maryâ&#x20AC;&#x2122;s/ Mt. Carmel Clinic. This area has seen several periods of no physician coverage at all, especially in 2005 and 2006, and has experienced challenges in recruiting locum physicians. Table 28 describes the history of general practitioner coverage at the Shamrock Clinic in Ferryland. This service, staffed with two physicians, has been somewhat more stable than the sole physician service in St. Maryâ&#x20AC;&#x2122;s/Mt. Carmel.

* Full complement is one salaried physician

* Full complement is two salaried physicians

Focus group participants expressed concern about lack of access to physician care after hours (evenings and weekends) in some areas (St. Maryâ&#x20AC;&#x2122;s/Mt. Carmel). They felt this gap in service was resulting in increased use of ambulance service, at a significant cost to the health care system. Telephone respondents were asked to name the number one health service priority in their area. They identified family doctors as their top priority: 50% of respondents noted it as the top priority in Region B (Portugal Cove South to North Harbour); 29% of respondents noted it as the top priority in Region C (Branch to Long Harbour) and 25% of respondents noted it as the top priority in Region A (Bay Bulls to Renews). When asked specifically about general practitioner services, 88% of telephone survey respondents reported that they had a regular family doctor. This is similar to the number reporting a family physician in the Burin Peninsula survey (88.7%). Table 29 shows responses to this question by region, indicating that Region C had the lowest percentage of people without a family doctor.

The population of the Southern Avalon region (2001 census) is approximately 17,610. There are currently 13 general practitioners serving this population, therefore, the ratio of general practitioners (Southern Avalon) per 100,000 people is 73.82. This ratio is only slightly less than the Burin Peninsula ratio of 75.9 per 100,000 population.44 The Canadian Institute for Health Information notes that for the Eastern Regional Health Authority in Newfoundland and Labrador, the ratio of general/family physicians is 89 per 100,000 population, for the province of Newfoundland and Labrador the ratio is 99 physicians per 100,000 population and for Canada the ratio is 97 physicians per 100,000.45 All of these calculations are based on 2001 census data. Telephone survey respondents indicated that they had been with the same family doctor for a significant number of years (75% indicated 5 years or more with the same family doctor).

General Practitioner wait times are not significant, based on feedback from the telephone respondents. Seventy-eight per cent (78%) of respondents reported being able to see their doctor by the next day, and a further 18% were able to see their doctor within a week.

There was no significant difference between regions on wait times for an appointment with a physician. A nurse practitioner (primary health care) is a registered nurse with advanced preparation obtained through a nurse practitioner program. Nurse practitioners work under scope of practice guidelines established by the Registered Nurses Act. Their scope of practice includes the authorization to refer to a physician, including specialists; make and communicate a diagnosis; order laboratory or other diagnostic tests; prescribe a drug (as prescribed in regulation or a practice protocol issued to them) and provide emergency care. Nurse practitioners can provide prenatal care and well women services, including pap tests and clinical breast exams, provide patient education and counselling and manage patients with stable chronic diseases such as diabetes, thyroid disease, hypertension and asthma for up to one year. They can also treat acute illnesses such as influenza, sore throats, ear infections and sprains. A nurse practitioner has been employed in a primary health care role at the St. Mary’s/Mt. Carmel Clinic (permanent position) since May 2002, and at the Placentia Health Centre since January 2006 (the later is a temporary position associated with the Placentia Primary Health Care Renewal Initiative). Informants and focus group participants were uniformly supportive of the nurse practitioner service and questioned whether it would be cost-effective and improve care to expand the service by hiring additional nurse practitioners. Their positive comments centred on the consistent care received from the nurse practitioners as well as their local knowledge and commitment to their communities. Telephone respondents who had used the nurse practitioner service also expressed satisfaction with the service. Table 32 provides an overview of nurse practitioner utilization for St. Mary’s/Mt. Carmel clinics from 2003-2006. The nurse practitioner has regular clinic hours at both locations and is involved in health promotion, illness/injury prevention, primary care, rehabilitative and supportive care. The utilization of nurse practitioner service is higher in the 2004-05 period; this corresponds to a period of physician vacancy in the area.

The nurse practitioner position at the Placentia Health Centre works intensely with the collaborative practice model of diabetes care (Placentia Primary Health Care Renewal Initiative). She sees patients in the clinic at the Outpatients Department (1028 appointments this fiscal year to January 23, 2007); is the leader in the delivery of the cervical screening program in the area (has regularly scheduled Well Women Clinics in Placentia, St. Bride’s and Whitbourne); participates in Well Men and Well Teen Clinics and in Rural Women’s Health Days. She is scheduled for regular visits at the Lions’ Manor long term care facility; the service there is well-established (543 long term care visits in the past year).

Community health nurses contribute a variety of services in health promotion and protection and continuing care to the communities and people in their region. They are responsible for providing direct nursing care, either from the ambulatory clinics they offer at their office, or through home visits to clients. In their continuing care role, they provide follow-up care to patients discharged from acute care settings, ongoing care for persons with chronic conditions, and complete assessments on clients requiring home support and those seeking admission to personal care homes or long term care facilities. They conduct immunization clinics, provide health education and consultative services, and refer clients to other health providers. Community health nurses encourage community mobilization for healthy living, and work with community groups to motivate and facilitate this process. They participate in a number of community health projects, such as school health teams. Community health nursing service covers all communities in the Southern Avalon from the following work sites; Witless Bay, Ferryland, Trepassey, St. Mary’s, St Joseph’s, Placentia Health Centre and St. Bride’s. Focus group participants and key informants identified community health nurses as key people in providing service. For many people in the community, the community health nurse is their first point of contact; people often turn to the nurse as their “guide” to help them navigate through the complexities of the health care system. They are regarded as very knowledgeable about needs in the community, key links with other members of the health care team and other Eastern Health partners. Of the telephone survey respondents who utilized the service of a community health nurse in the past year, 91% were somewhat or very satisfied. Pharmacists are viewed by key informants and focus group participants as key players in providing primary health care in a rural setting and essential team members. In addition to patient counselling, pharmacists also play an important role in helping individuals find their way through the health and community services system and serve as an advocate for their patients. Free home delivery service is provided by many rural pharmacies and this assists individuals who do not have access to transportation or who live on fixed incomes. Several focus group participants and key informants mentioned that it was not uncommon for pharmacists to go out of their way to ensure medication is available to patients, especially those who are challenged in their ability to pay and not covered by the provincial drug program or private insurance. Pharmacy services are available in Bay Bulls, Ferryland (co-located with the Shamrock Clinic), Trepassey (co-located with the Nurse Abernathy Clinic), St. Mary’s (co-located with the St. Mary’s Clinic) and Placentia (two pharmacies). In most of these communities the pharmacist is a sole practitioner and works alone or with a pharmacy technician. Coverage for pharmacists’ leaves is difficult to obtain, especially as the community depends very much on the service being available to them. Dental (oral) health was raised by key informants and focus group participants as an area of concern, especially in those areas where dental service is unavailable except at a distance (St. Mary’s Bay area, Trepassey and area). Key informants and focus group participants noted that people often ignore their dental health until there is a crisis, either because getting dental service means significant travel, or because they do not have adequate income to pay, either for the travel or for the service itself. Several examples were provided of persons on income support who are unable to get subsidized dental coverage for restorations (fillings), only for extractions. Data from the telephone survey indicates that a large number of persons surveyed did not visit a dentist in the past twelve months: 52% in Region A (Bay Bulls to Renews), 63% in Region B (Portugal Cove South to North Harbour), 51% in Region C (Branch to Long Harbour).

There is one dentist in the Placentia area who sees patients from 9:30-12:00 and 2:00-4:30 on Mondays, Tuesdays and Thursdays and also for 3 hours on Friday mornings (18 hours per week); he is taking new patients. There is one dentist dividing his practice between Ferryland (two days a week) and Holyrood; this dentist is accepting new patients. Clinics in Ferryland have been reduced due to periodic closure of the Witless Bay Line during bad weather. The concern with oral health status, particularly related to childrenâ&#x20AC;&#x2122;s oral health, is confirmed when analyzing day procedure utilization data from the Janeway Childrenâ&#x20AC;&#x2122;s Health and Rehabilitation Centre and the Carbonear General Hospital for the past three years.

Data Source: CIHI portal * Dental surgery is the most common day procedure for patients from Southern Avalon communities who require service at the Janeway. At the time of this needs assessment, dental clinic utilization (at the Janeway) for children from the Southern Avalon was unavailable.

Emergency service (hospital service) and ambulance service were both viewed as important health service priorities by the respondents to the telephone survey. The nearest 24-hour hospital emergency service for the Irish Loop section of the Southern Avalon (Bay Bulls to St. Mary’s Bay) is in St. John’s (St. Clare’s Mercy Hospital Emergency or Health Sciences Emergency). Placentia Health Centre provides a 24-hour emergency department. Utilization of this service shows an increase of approximately 9% in ER registrations from 2003/04 to 2005/06. Key informants and focus group members generally agreed that local emergency responders (ambulance service) provided a good service and a quick response. In the telephone survey, 72% of those who expressed an opinion on ambulance service said they were “very satisfied” and reported that they had, in all cases, used the ambulance system solely for an emergency. At the time of the needs assessment, ambulance service was available from the communities of St. Bride’s, Placentia, St. Mary’s, Mt. Carmel, Trepassey, Renews and Ferryland. Key informants and focus group participants questioned whether the ambulance service was operating in the most effective way possible. In particular, some questions arose about utilization of ambulance service from Trepassey and St. Mary’s Bay/Mt. Carmel area. Table 35 provides an analysis of types of medical transports in these particular areas over the past three years.

Data source: Eastern Health, Division of Paramedicine and Medical Transportation database

A service review of ambulance service for the entire Eastern Health region is currently being carried out by Eastern Health’s Division of Paramedicine and Medical Transport. During the course of the needs assessment, the provincial government announced that it would engage an outside consultant to analyze medical transportation service (provincewide) provided to clients receiving income support. Mental Health and Addictions Services were identified as a need by key informants and focus group participants from all areas of the Southern Avalon; the need for enhanced service in this area emerged as one of the key themes of this needs assessment. In particular, the need for some type of ongoing community-based support for persons with chronic mental illness was identified. The focus of the service should be geared to the needs of people within their communities and include mental health promotion. Currently, there are mental health counsellors working from Eastern Health’s Witless Bay office (covering the Southern Shore to St. Shott’s with scheduled office hours of one day a week in both Ferryland and Trepassey and three days a week in Witless Bay), the Holyrood office (covering the Salmonier Line to St. Vincent’s and offering bi-weekly mental health clinics in St. Mary’s) and Placentia (covering clients from the east side of Placentia Bay and the Cape Shore). There is also a relatively new mental health case management service offered out of the Holyrood office (targeting clients with challenging case management issues related to mental health).

Key informants and focus group participants expressed concern that services currently available to address mental health and addictions needs were not well-known in communities. Other issues related to the service include the perception that it is difficult to get an appointment with a counsellor because of long wait times. Another hurdle pointed out was the travel required to access the service, and the associated costs. For example, a person living in Branch who needs mental health counselling must travel to Placentia for the service. Still another issue identified was the real difficulty that general practitioners have in obtaining referrals to psychiatric service for their patients. The need for mental health services was linked by key informants and focus group participants to the uncertain future facing some communities, the depression associated with out-migration and lack of social support (especially for seniors) and the feeling that many people have that they are living in an area where “the community is slowly dying.” (Key Informant). Youth do not appear to be immune to these stresses. Youth focus group participants identified “stress” in their lives (related to many factors, including the lack of local employment options in their future, school and peer pressure and pressure on their families due to declining economic prospects in their communities). Addictions (to alcohol, prescription and illegal drugs) were frequently mentioned by key informants and focus group participants as an important area to address. There were comments about the proliferation of alcohol at social events in communities and the acceptance of overindulgence in alcohol as a social norm. Drunk driving was viewed as a major problem in their community by 15% of telephone respondents; illegal drug use by 22% of respondents. Telephone survey respondents identified Mental Health Services as one of the top five health service priorities in their communities; 10% of telephone respondents rated their mental health as poor or fair; 21% viewed loneliness as a major problem affecting the health and well-being of members of their community. Eastern Health has developed a strategy to improve mental health and addictions service in the region (Working Together for Mental Health - a Regional Action Plan for Eastern Health, July 2005). This strategy identifies five key policy directions and associated action steps. These directions include: enhancing prevention and early intervention, involving consumers and significant others, building bridges for better access, providing the best clinical service and demonstrating accountability and measuring progress.46 Feedback received during the Southern Avalon Needs Assessment process indicates that there is a continued need to focus on these policy directions and review the status of this plan. In the Bay Bulls to St. Shott’s area, 70% of clients are receiving service for mental health issues and 30% for addictions. Service is provided on an emergency and priority basis; average wait time for mental health service is 5-6 months, for addictions service the average wait time is 6-7 months. The current workload for the counsellor (serving the area from Bay Bulls to St. Shott’s) is 31 cases with a wait list of 32. Numbers of clients waiting for mental health services/addictions services has varied over the past three years. The most significant client issues (in terms of volumes of cases) being treated (2007) are those related to substance abuse, relationships, abuse (not sexual abuse), bereavement, and suiciderelated. Utilization data for the mental health services offered from Placentia (full time service) and St. Mary’s (bi-weekly clinic) indicates that 17 new cases have been opened in Placentia between April 2006 and February 2007, while 9 new cases have been opened in the St. Mary’s office. As of February 2007, there were 13 individuals waiting for service in Placentia and 1 in St. Mary’s. The approximate wait time for mental health service in Placentia is 2 weeks. Clients are presenting with a variety of concerns, the most common of which are mood and anxiety disorders and victims of abuse. Addictions service is available in Whitbourne with a bi-weekly clinic held in Placentia.

The need for access to more community-based rehabilitative services, such as physiotherapy, occupational therapy and clinical dietitian service was raised frequently by key informants and focus group participants. These services are only available in the Southern Avalon on a very limited basis. The perception is that needs are much greater than the current service being provided. Eastern Health’s utilization data indicates limited interventions in the Southern Avalon from rehabilitative services in the past three years.

Data source: CRMS database * Numbers reflect combined service counts from the former Health and Community Services, St. John’s Region and Health and Community Services Eastern. ** Physiotherapy service only available in the Bay Bulls-St. Shott’s area of the Southern Avalon.

Laboratory and X-ray services are available at the Placentia Health Centre; some laboratory service and general X-ray service is available at the Abernathy Clinic in Trepassey. There has been a decline in X-ray volumes at Trepassey in the past three years (20% decline in number of X-rays from 2003/04 to 2005/06). Workload units at Placentia Health Centre have also declined for Lab/EKG (14% decline in workload units from 2002-03 to 2005-06). Blood collection service is available at the Shamrock Clinic in Ferryland, and has been available since January 2006 on a limited basis (18 hours bi-weekly) at the St. Mary’s and Mt. Carmel clinics. Use of the latter service has been relatively constant at 70-100 blood collections per month. No testing is done at these sites - the specimens are delivered to St. John’s. Key informants and focus group participants identified several issues and concerns related to diagnostic testing. They noted the significant aging of the population and the consequent increase in the numbers of people needing monitoring (such as those on blood thinning medications). They noted the difficulty in getting to a larger centre (such as travelling from Branch to Placentia) on a regular basis to have blood drawn. They questioned whether costs associated with transport by ambulance to have blood drawn were appropriate. They would like blood collection options available that would not require travelling a long distance. Several challenges were noted with the Trepassey lab and X-ray service. The technician in Trepassey is cross-trained to deliver both general X-ray and laboratory services, however this cross-training is no longer available. (The College of the North Atlantic offers a 1-year program for laboratory technicians; completion of this program provides them with the skills they need to perform basic X-ray procedures. Recruitment for this program and for laboratory technician positions in general, is difficult.) In addition, according to a review done by the Biomedical Department (Infrastructure Support, Eastern Health) the general X-ray machine in Trepassey is over 25 years old. There are no longer parts available to repair it if it were to become defective and the cost to replace this system is approximately $170,000.

Health Line is a primary health care telephone advice and referral service begun in September 2006 and operated by Clinidata under contract to the Department of Health and Community Services. Several of the focus groups mentioned the service positively and suggested this was a good addition to primary health care service, especially for rural Newfoundland and Labrador. A review of utilization data for the period October 2006-January 2007 for the Southern Avalon indicates that there were 396 calls to the service during the period. Table 37 describes the type of calls and callers.

Data source: Clinidata: HealthLine Service Report for the NL Department of Health and Community Services (Special Report: Southern Avalon)

Hospital discharge data for the Placentia Health Centre provide details on utilization of the ten inpatient beds. Canadian Institute for Health Information applies a grouping methodology to put like cases using like resources into one group called a Case Mix Group (for inpatients). Table 38 describes the top five Case Mix Groups for the Placentia Health Centre for the years 2003-2005, the average length of stay and the average age of the patients.

Data source: CIHI Portal * Further analysis of this case mix group indicates that these cases are patients who received palliative care.

Secondary Health Services Secondary health care for the Southern Avalon is provided through referral to facilities and services in St. John’s (adult and child acute care facilities) and the Carbonear General Hospital. This secondary health care can involve either outpatient services or admission. The following tables (Table 39 - Table 41) describe the top five (numbers of patients) case mix groups related to hospital discharges; they provide an insight into the reasons why people from the Southern Avalon have been hospitalized.

Table 40 examines discharge data (Southern Avalon patients) for St. John’s adult hospitals in the period 2003-2005. Three of the top five case mix groups are similar for both St. John’s adult acute care and Carbonear hospitals (digestive related, uterine related and chronic bronchitis).

Data source: CIHI Portal

The most common day procedure carried out on adults from the Southern Avalon (2003-2005) at both the Carbonear General Hospital and at St. John’s adult acute care hospitals was gastro-intestinal (433 cases at the Carbonear General Hospital during this period; 2,146 cases at St. John’s adult hospitals). Secondary health services for children are provided at the Janeway Child Health Centre in St. John’s. A review of the top five case mix groups at the Janeway for children from the Southern Avalon is provided in Table 41.

Data source: CIHI Portal

Dental surgery is the top day procedure at the Janeway Child Health Centre for children from the Southern Avalon (116 cases from 2003-2005; average age 8). This reinforces comments heard from key informants and focus group participants who indicated that oral health of children was a significant concern in the region. 7.3.3. Recommendations 1. Develop a primary health care framework that addresses strategies for the delivery of services in the Southern Avalon, with particular attention to team development, scope of practice, physician retention issues and community linkages. 2. Promote linkages between community pharmacists and other members of the primary health care team by discussing and implementing means to facilitate improved communication, teamwork and patient/client care. 3. Develop a plan to address current and future needs of the laboratory and X-ray service at Trepassey, incorporating consideration of present and future human resource requirements and equipment needs and involving all partners - including Eastern Health’s regional Diagnostic Imaging and Laboratory Medicine departments. 4. Evaluate blood collection needs in rural areas of the Southern Avalon, to determine business case for potential innovations in service.

5. Advocate that the provincial government address oral health needs and gaps through expanded dental services by a) enhancing services offered to persons on income support and those with low income, and b) considering the provision of mobile clinics for rural areas currently underserved by dental services - supported, where possible, by Eastern Health space. 6. Provide a status report to the organization and the community regarding implementation of Eastern Health’s Regional Action Plan for Mental Health and Addictions, with particular focus on outstanding issues related to rural service recommendations. Continue to advocate for funding for current plan. 7. Improve our understanding of the impact of chronic disease (or specific chronic diseases) in the Eastern Health region by collecting and analyzing region-specific surveillance and intervention data. 8. Partner with the Department of Health and Community Services in developing and implementing a chronic disease management strategy that is consistently applied across the Eastern Health region.

8. Determinants of Health (Other) Section 8 examines the remaining determinants of health and their impact on population health on the Southern Avalon. The determinants that will be discussed are: ◆ Income and Social Status ◆ Employment and Working Conditions ◆ Social Support Networks ◆ Education ◆ Social Environments ◆ Physical Environments ◆ Personal Health Practices and Coping Skills ◆ Gender and Culture ◆ Biology and Genetic Endowment Data on many of these determinants of health has been retrieved from Community Accounts (http://www.communityaccounts.ca), a resource of the Newfoundland and Labrador Statistical Agency. Indicator data was retrieved from Community Accounts based on the boundaries of two economic zones (Economic Zone 18 - Avalon Gateway and Economic Zone 20 - Irish Loop). These economic zones correspond to the boundaries of the community health needs assessment for the Southern Avalon. This section of the report will conclude with a discussion of the importance of “place” when considering community health needs of largely rural areas such as the Southern Avalon.

8.1. Income and Social Status It is very challenging to be healthy when you have a low income. Your choices (such as where you live and what type of housing you can afford, how much and what type of food you can buy, the recreation you can enjoy, etc.) are limited by your income. Your income determines your social status; health status improves at each step up the income and social hierarchy ladder you are able to advance. A higher income and social status generally results in more control in your life and more ability to make decisions. Income and social status appear to be the most important determinants of a person’s health.47

Findings - Southern Avalon Four indicators provide a picture of Southern Avalon income levels (the economic self-reliance ratio, social assistance incidence, personal income per capita and average couple family income). They demonstrate that the region has challenges in this area. Economic Self-Reliance Ratio A communityâ&#x20AC;&#x2122;s self-reliance ratio measures its dependency on government transfers such as Canada Pension, Old Age Pension, the guaranteed income supplement, social assistance, and employment insurance. The higher the percentage of income that comes from government transfers, rather than earned income, the lower the self-reliance ratio. The economic self-reliance ratio (2004) for Economic Zone 18 (Avalon Gateway) was 68%; for Economic Zone 20 (Irish Loop) the economic self-reliance ratio was 70%. This means that 32% of income in the Avalon Gateway region and 30% of income in the Irish Loop region originates from government transfers rather than from earned income. The provincial self-reliance ratio for 2004 was 78%.48 Figure 17 shows the self-reliance ratios (2004) for all economic zones within Eastern Health (Economic Zone 15 - Discovery, Economic Zone 16 - Schooner, Economic Zone 17 - Mariner, Economic Zone 18 - Avalon Gateway, Economic Zone 19 - Capital Coast and Economic Zone 20 - Irish Loop). It indicates that Economic Zone 18 - Avalon Gateway is the area most reliant on government transfers. Data source: Community Accounts (NL Statistical Agency) * Southern Avalon Economic Zones 18, 20

Social Assistance Incidence Social assistance income (also known as income support) provides income for the most basic costs of living. In 2003, the social assistance incidence in Economic Zone 18 (Avalon Gateway) was 12.3%; for Economic Zone 20 (Irish Loop) the incidence of social assistance was 9.1%. At the provincial level, social assistance incidence in 2003 was 13%.49 Figure 18 illustrates the incidence of social assistance for all economic zones within the Eastern Health region. The figure shows that Economic Zone 20 (Irish Loop) has the lowest incidence of social assistance (2003) for the economic zones within Eastern Health. Economic Zone 18 (Avalon Gateway) has an incidence of social assistance similar to Economic Zone 19 (Capital Coast - this zone includes the city of St. Johnâ&#x20AC;&#x2122;s).

Personal Income per Capita The personal income per capita in 2004 for Economic Zone 18 (Avalon Gateway) was $17,600; for Economic Zone 20 (Irish Loop) it was $19,000. For the province, personal income per capita in 2004 was $20,600.50 Figure 19 compares the personal income per capita for all economic zones within Eastern Health for 2004. Personal income per capita in Economic Zone 18 (Avalon Gateway) ranks second lowest of all the economic zones in the Eastern Health region. Personal income per capita in Economic Zone 20 (Irish Loop) was near the provincial measure and second-highest for the economic zones within the Eastern Health region.

Data source for figures 18 & 19: Community Accounts (NL Statistical Agency) * Southern Avalon Economic Zones 18, 20

Average Couple Family Income The average couple family income (2004) for Economic Zone 18 (Avalon Gateway) was $48,400; for Economic Zone 20 (Irish Loop) it was $54,900. Average couple family income in the province in 2004 was $51,800.51 Figure 20 compares average couple income (2004) in the six economic zones within Eastern Healthâ&#x20AC;&#x2122;s boundaries. It illustrates that average couple income in Economic Zone 20 (Irish Loop) was the second highest within the Eastern Health region in 2004. (Economic Zone 18, Avalon Gateway ranked fourth out of six). The Southern Avalon has income levels (as demonstrated by the indicators above) that are most likely having an impact on the health of the people in the region. While both economic zones are challenged in terms of income levels, Economic Zone 18 (Avalon Gateway - which includes the town of Placentia) has lower per capita and family income and a higher incidence of social assistance. This corroborates findings from the key informant and focus group discussions, where poverty was cited as a key health-related challenge in this area. Statistics Canada calculates low income cut-offs (LICOs) for various regions throughout Canada. This threshold reflects the point at which families are likely to spend 20% more of their income on necessities, such as food and shelter. Being below the LICO is seen as an indication that a family may face economic difficulties. We can see the prevalence of low incomes in the Southern Avalon by examining Table 42 which represents the number of Southern Avalon telephone survey respondent households which fall below the LICO in each region. For the Southern Avalon region as a whole, 17.2% of respondent households fall below the LICO. At 22%, Region B has the highest rate of respondent households below the LICO. Provincially, 16.3% of households are below the LICO;52 the national occurrence of families below the LICO is 15.5%53 The Burin Peninsula Survey found that 34% of respondentsâ&#x20AC;&#x2122; households fell below the LICO.54

Data source: Community Accounts (NL Statistical Agency) * Southern Avalon Economic Zones 18, 20

Key informants and focus group participants identified the following health-related issues associated with low income: Low and limited incomes make it difficult to buy healthy food. While many key informants and focus group participants praised the increased focus on healthy eating in the schools, they pointed out that knowing what to eat does not make nutritious food more readily accessible if you have a low income. The importance of a good diet was acknowledged - people realize that dietary intake and nutritional status have an important role to play in preventing some chronic diseases and cancers as noted in the 2003 report Nutrition Newfoundland and Labrador.55 However, the concern raised by many focus group participants and key informants is that many people cannot afford to eat properly. The ability of Newfoundlanders and Labradorians with low incomes to afford sufficient, nutritious food was reviewed in the discussion paper The Cost of Eating in Newfoundland and Labrador - 2003 prepared by the Dietitians of Newfoundland and Labrador, the Newfoundland and Labrador Public Health Association and the Newfoundland and Labrador Association of Social Workers. This review concluded that many Newfoundlanders and Labradorians with low incomes are unable to buy sufficient nutritious food.56 The Community Advisory Committee of the Placentia Primary Health Care Renewal Initiative has identified food security as a significant issue in their community. They have taken a proactive approach and are working with the local food bank on raising awareness of the issue in the community and revamping the food bank service. A recent news article in The Charter, Placentiaâ&#x20AC;&#x2122;s weekly paper, highlighted the service and the fact that 20% of Placentia area residents are regular food bank users, and described the needs of the people using it.57 In the telephone survey conducted for this needs assessment, 25% of respondents indicated that maintaining a healthy diet was a major problem in their community.

Low and limited incomes make it difficult to pay for medications. Several key informants noted the challenges faced by people with limited income (those who do not qualify for drug coverage) in obtaining the medications they need. Numerous examples were given of people who cannot afford their medications so go without them, or who take medications improperly (taking a pill every second day instead of every day, for example) to decrease the cost. On numerous occasions, key informants mentioned the number of people who depend on free samples from physicians as their only way to get the medication they require. While the province of Newfoundland and Labrador recently increased the eligibility threshold for drug coverage as an initiative of its Poverty Reduction Strategy, the anticipated positive impact had not yet been noted at the time the key informant interviews and focus groups took place. Some focus group participants expressed concern that the approval process to access this expanded drug coverage may be challenging for those who could potentially benefit from the expanded coverage regulations. Lack of money for transportation is an issue. Living in a rural area like the Southern Avalon means that services (grocery stores, government offices, health clinics, pharmacies) are at a distance. People who have low incomes often have no transportation and may live in areas where public transportation options are limited or costly. While there is some transportation assistance for those on income support, there are still challenges to overcome. A focus group participant described the situation of someone living on the Cape Shore who was receiving income support and needed mental health counselling. The counselling service is available in Placentia, but because the recipient of the service is considered to be living â&#x20AC;&#x153;in districtâ&#x20AC;?, her travel to Placentia for this counselling is not covered by Human Resources Labour and Employment (HRLE). This barrier to service (unless it is overcome) may mean that the individual goes without service and the situation could escalate to a crisis, at which time the costs to the individual and the health care system are much greater. Lack of money for non-insured services is an issue. Several key informants and focus group members identified needs around some services, such as dental procedures, where a lack of insurance coverage was discouraging some people from accessing the service. In the telephone survey conducted for this needs assessment, 35% of respondents reported having dental insurance.

8.2. Employment and Working Conditions A person with a job that provides him/her with enough money to meet his/her needs and the needs of his/her family will tend to be healthier than a person without a job. If a personâ&#x20AC;&#x2122;s employment status is unstable, unsafe or stressful, this will be a challenge to their health. Jobs provide income, and income is a crucial determinant of health. In addition to providing income, a job can provide a person with a positive self-image, a sense of identity and purpose, social contacts and an opportunity for personal growth. Findings In the Southern Avalon region, employment and working conditions can be analyzed through examining several indicators: the makeup of the local economy, the employment rate, the change in employment and the incidence of employment insurance.

Makeup of the local economy The economy of the Southern Avalon region is based on employment available from several sources, including public services provided by various levels of provincial, federal and municipal departments and agencies of government (including health and education), seasonal fishery-related activity (harvesting and processing), the retail trade, tourismrelated services such as accommodations and food services, and some construction and manufacturing activity. In December 2005, there were 213 businesses listed for Economic Zone 18 (Avalon Gateway) and 266 businesses listed for Economic Zone 20 (Irish Loop). These businesses reflected 1.3% and 1.9%, respectively, of the total businesses for the entire province as of December 2005.59 Employment Rate The employment rate describes the per cent of the population aged 18-64 who reported employment income in a particular year. In 2003, the employment rate in Economic Zone 18 (Avalon Gateway) was 75.1%; for Economic Zone 20 (Irish Loop) the employment rate was 79.1%. These employment rates are similar to rates for the other economic zones included within the Eastern Health region for the same period, as illustrated in Figure 21. The employment rate for the province for 2003 was 76.5%.60

Data source: Community Accounts (NL Statistical Agency) * Southern Avalon Economic Zones 18, 20

Change in Employment Measuring the changes in employment over time in the Southern Avalon helps to understand the trends that may be occurring. For the period 1998-2003, employment in Economic Zone 18 (Avalon Gateway) dropped 2.2%; for the same time period, employment in Economic Zone 20 (Irish Loop) grew by 1%. Figure 22 illustrates the changes in employment (19982003) in the six economic zones included within the Eastern Health region. Within the same period, employment in the province grew by 5.9%.61

Data source: Community Accounts (NL Statistical Agency) * Southern Avalon Economic Zones 18, 20

Employment Insurance Incidence Employment insurance provides income for persons laid off from their work, such as those working in seasonal industries. In 2004, 55% of the workforce in Economic Zone 18 (Avalon Gateway) received employment insurance; 56% of the workforce in Economic Zone 20 (Irish Loop) received unemployment insurance. These areas of the Eastern Health region have the highest incidence of employment insurance, as seen in Figure 23. For 2004, the incidence of employment insurance in the province was 36.6%.62

Key informants and focus group participants identified the following employment-related issues that are having an impact on health in the Southern Avalon. There is a lack of stable local employment options. Many key informants noted the lack of jobs in the Southern Avalon. (The exception noted was those communities within easy commuting distance of the greater St. John’s area). The majority of key informants identified the lack of employment as the most significant determinant of health for the Southern Avalon. They noted that employment, whether it is full time or seasonal, is often the determining factor in levels of personal and family income. In the telephone survey conducted for this community health needs assessment, 53% of respondents identified unemployment as a major problem in their communities. Key informants and focus group participants were open about their fears for the future of their communities in the absence of some significant economic development. Many of them commented on the “roller-coaster” experience in the Placentia area where, over the past ten years, there have been high expectations for significant economic growth and corresponding disappointment when the promised developments did not proceed. Although still hopeful about current developments with Voisey’s Bay Nickel Company, the common refrain from many of the key informants was “I’ll believe it when I see it.” In the opinion of many key informants and focus group participants, the lack of jobs in the area has been the driving force in the significant out-migration from the Southern Avalon. Some people who have left the area for work have adapted to the life of a migratory worker. For others, the strain of being away from their families for extended periods of time (and the pressure on the family members left at home to cope with their absence), was cited as contributing to increased stress. People unable or unwilling to travel out of their community or the province to find work are left wondering from year to year what local job prospects (often solely seasonal work) will be available for them. Youth focus group participants identified the economic uncertainly in the local area as adding to their stress.

“I have no reason to get up in the morning.” - Key Informant, referring to lack of work.

Communities need to work together on regional initiatives for economic development. Key informants and focus group participants acknowledged that communities need to work together in a regional approach to economic development. They understand that pitting one community against another in terms of attracting small business or industry is counterproductive. Some examples of this move to a more regional approach in the Southern Avalon are evident in the work of the regional economic development boards.

“We can’t go it alone. We need to cooperate.” - Key Informant

8.3. Social Support Networks Social support networks are caring family, friends and communities that provide support to individuals in solving their problems and overcoming obstacles in their life. When we have a good network of people who love and support us, there is a greater likelihood that we will manage our challenges and weather the stress and crises we may encounter in our lives. Having a social support network can also provide a sense of satisfaction and well-being and seems to act as a buffer against health problems. Social support networks are likely to be more evident in stable, economically secure communities.63 Findings A community health needs assessment gathers information about the health-related needs of a particular area from both a factual and an opinion perspective. The assessment identifies key themes, prioritizes needs, develops recommendations and lays out an action plan. In this way, information is translated into knowledge that can be used for action. We can assess the social support networks available on the Southern Avalon by looking at the stability of communities. This stability is challenged by the population decline that is evident in the region. Demographic trends are threatening long-standing social support networks. Key informants and focus group participants recounted the strong community support that is a tradition in the Southern Avalon. People are quick to respond to neighbours in difficulty (because of family emergencies, illnesses, or disasters). They described the outpouring of support and aid provided to those in need. However, they acknowledged that communities experiencing out-migration are more challenged to provide the ongoing social support that people need to promote mental and physical health. Some anecdotes were relayed of people left without a social support network because their immediate and extended family members have moved away. Migration Rates Migration rates indicate the phenomenon of people moving out of their communities to another location. A period of increased migration occurred in the Southern Avalon after the cod moratorium (1991-1992). The migration rate for 1991-1996 for Economic Zone 18 (Avalon Gateway) was 11.8%; for Economic Zone 20 (Irish Loop), it was -9.3%. For the same period, the migration rate for the province of Newfoundland and Labrador was -5.1%.64 Figure 24 describes migration rates (1991-96) for all the economic zones within Eastern Health and for the province. Economic Zone 18 (Avalon Gateway) experienced the most significant migration from within the Eastern Health region during this period.

Data source: Community Accounts (NL Statistical Agency) * Southern Avalon Economic Zones 18, 20

Migration has continued to be a significant issue with most communities in the Southern Avalon. Telephone survey respondents (68%) indicated that out-migration was a major problem in their community. Some key informants questioned whether social support networks such as church groups, community organizations, support groups and family networks would remain viable should the population continue to decline. In spite of these developments, respondents to the telephone survey seemed relatively happy with the social support they have from family and friends 29% rated it as excellent, 27% rated it as very good, 34% as good. (Seven per cent rated their social support from family and friends as fair, 3% as poor). Some seniors are experiencing a lack of social support as a result of out-migration. The population of the Southern Avalon is aging. By 2021, it is estimated that over 30% of the total population in Economic Zone 18 (Avalon Gateway) and Economic Zone 20 (Irish Loop) will be 65 years or over.65 Many seniors depend on family and friends for socializing, transportation to appointments and community events and support with things such as home maintenance.

“We are becoming a community of seniors.” - Key Informant

While many informants cited the family network as a strength in their area and stated that people really pulled together in times of crisis, they admitted that with so many younger persons leaving their communities for work elsewhere, some seniors were being placed in a vulnerable position. This lack of social support was seen as a key reason for loneliness, increased depression, lack of attention to maintaining a good diet, and inability to “keep things going”. Several communities are trying to overcome this social isolation by establishing new social support networks to reach out to seniors who may need additional support. The community of Branch has developed a free meal service and social gettogether for older adults (The Singing Kitchen). The seniors in Trepassey have been particularly energetic in trying to make sure that their fellow seniors get out to events, take part in activities and get the support they need. They have also developed an inventory of seniors and volunteers who are able to assist with the seniors’ needs. Need for local support groups. Key informants and focus group participants noted a lack of support groups in the community. Parenting support groups were mentioned as a particular need in light of the numbers of lone parents coping with raising families by themselves. Some areas of the Southern Avalon are seeing an increase in one parent going away to work for long periods of time, leaving the spouse behind to manage the day-to-day needs of the family. In some instances, these spouses may experience social isolation and stress from having to manage family and other responsibilities alone. Support groups for seniors and for persons coping with mental illness were also noted as important needs in the area. Alcoholics Anonymous was mentioned as having an important presence and providing support through several groups in the Southern Avalon. Lack of support groups was noted by 29% of telephone survey respondents as a major problem in their community.

8.4. Education A person’s level of education is strongly linked to their health status. Education provides people with knowledge and skills for problem solving, and increases the probability that they will have a job to provide them with income and contribute positively to their self-esteem. Low literacy levels make it more difficult to obtain a job; people with low literacy often suffer from unemployment, poverty and have poorer health and die earlier than do people with high levels of literacy.66 Findings Educational Attainment According to Census 2001, more than half of residents aged 20+ on the Southern Avalon have high school education or above. In Economic Zone 18 (Avalon Gateway), 56.9% of the residents aged 20+ have a high school education or above; in Economic Zone 20 (Irish Loop) the total is 55.3%. This compares to 60% of people in the entire province. Figure 25 illustrates how the Southern Avalon compares, in high school graduation rates, to the other economic zones in the Eastern Health region.67 High school graduation rates for the Southern Avalon are slightly under the provincial attainment. Many key informants remarked on the high numbers of young people leaving the area and the province immediately after high school to go to Western Canada where high-paying jobs are available. This seems to be an increasingly common trend for young people on the Southern Avalon. Several focus group participants questioned how well-equipped these young people will be post-boom, if they do not acquire a skilled trade or advance their education. “I attended a high school graduation, and half the graduating class sent home congratulatory messages from Alberta.” - Key Informant

Data source: Community Accounts (NL Statistical Agency) * Southern Avalon Economic Zones 18, 20

The level of advanced education can be examined by noting the per cent of the population (aged 25-54) with a Bachelor’s degree or higher. In 2001, 4.7% of the population in Economic Zone 18 (Avalon Gateway), had a Bachelor’s degree or higher; 7.2% of the population in Economic Zone 20 (Irish Loop) were in this category. This compares to 11% of the population in the province who have attained a Bachelor’s degree or higher.68 Figure 26 indicates the per cent of the population in other economic zones of Eastern Health who have attained a Bachelor’s Degree or higher as compared to Southern Avalon rates.

Positive contribution of College of North Atlantic campus in Placentia noted. The Placentia campus of the College of the North Atlantic is viewed as contributing positively to the area; it attracts students from both within and outside the region. The recent success of the Process Operations course, a program for training workers for the INCO Demonstration Plant was cited as an example of creative partnering between the local college and Human Resources, Labour and Employment (HRLE). Participation in the program enabled some participants to move from income support to the paid work force. This demonstrates the importance of attaining skills training in order to access a good job.

â&#x20AC;&#x153;The College brings a lot to rural Newfoundland. Itâ&#x20AC;&#x2122;s an important player in the local economy.â&#x20AC;? - Key Informant

8.5. Social Environment The values and norms of a society influence the health and well-being of individuals and populations. These values are reflected in the social stability of a community, community safety issues such as the rates of crime, the level of tolerance of issues such as domestic violence and vandalism, the number of volunteers that participate in community organizations, the spirit of cooperation that exists within and between communities, and the respect for and recognition of diversity. Positive community responses to social issues can help individuals in their efforts to cope with change and foster health.69

Data source: Community Accounts (NL Statistical Agency) * Southern Avalon Economic Zones 18, 20

Findings Community volunteerism is a strong tradition in the Southern Avalon. Volunteerism was cited as one of the strengths of the Southern Avalon by key informants and focus group participants. There are many active community groups in the region, dealing with a broad variety of issues. These groups are associated with the church (such as Knights of Columbus), the schools (School Councils), crime prevention, emergency response (local fire departments), municipal government (town councils and local service districts), promotion of economic development (the Irish Loop and Avalon Gateway Regional Economic Development Boards, Trepassey and Argentia Management Authorities), local business promotion (Irish Loop Chamber of Commerce), community theatre (Colony of Avalon, Tramore, Placentia) and many more.

Voluntary groups are experiencing challenges. Many key informants and focus group participants mentioned that while volunteers were very committed to organizations, the number of volunteers is dropping. They attribute this to both the significant drop in population and its aging. This decrease in the volunteer base is a serious concern; some communities note they are having difficulty maintaining volunteer fire departments because of out-migration. Some community organizations may cease to exist because the volunteers are not there to run the organizations, or because volunteers are getting “burned-out”. With so many men working away, it is predominantly women who are keeping the volunteer organizations together. Cooperation between communities is growing, but issues remain. A healthy community is often the result of cooperation and sharing with neighbouring communities. Many examples were given of efforts made to promote a regional approach in the Southern Avalon. Two examples are in the municipal area - the Southern Shore Joint Council and the Southern Avalon-St. Mary’s Bay Joint Council. In these joint councils, municipalities share information, ideas and act together for the common good of the region. “We can’t go it alone. We know that.” - Key Informant Another positive example of regional cooperation is the 2006 Festival of the Sea - a joint effort of the Economic Zonal Boards. In this major initiative, a delegation from Ireland visited the Southern Avalon in the fall of 2006. The trip involved many volunteers from several communities in the region hosting, arranging events, entertaining, feeding and dialoguing together on issues of common concern to the region and the Irish visitors. While increased cooperation and a regional approach to tackling community issues is evident in many areas, tension between communities is evident from time to time. An example of this is the issue of the location of the Voisey’s Bay Nickel Company processing plant. In the fall of 2006, when the company decided to locate its plant in Long Harbour, Placentia protested loudly against what it perceived to be the breaking of a promise. The corresponding tension between the communities was resolved to a certain extent by the company agreeing to concessions for the town of Placentia in recognition of its “loss”. Domestic Violence. While violence in the home was not identified as a major issue by telephone respondents, some key informants did describe it as being a “hidden” issue in the communities of the Southern Avalon. The nearest transition house for victims of domestic violence in the Southern Avalon is in St. John’s (Iris Kirby House). Crime. The most common occurrences in the Southern Avalon region are related to substance abuse and property damage (vandalism and mischief). Some community-based crime prevention committees are in place, and the RCMP has developed linkages with schools and the P4 Youth Centre in the Placentia area.

8.6. Physical Environment The physical environment is an important determinant of health. It can influence health through the quality of the air, water, food and soil in our communities. Other factors related to the physical environment that have an impact on health include the general quality and availability of appropriate housing, and the overall design of communities and transportation systems in the region (including conditions of the roads). All of these elements can significantly influence physical and psychological well-being.

Findings Water, Air, Soil Quality Water quality is an ongoing problem for a number of communities in the Southern Avalon region, particularly in areas where drinking water from surface sources contains high levels of organics. There is a continued need for disinfection to deal with bacteria in the water, and concerns exist about the production and long-term exposure to the by-products of chlorination, (trihalomethanes or THMs). Boil water advisories are issued when water sampling and testing detects higher than accepted amount of coliforms or if there are deficiencies with regard to chlorination. At the time of this community health needs assessment, boil water advisories were in effect for the communities of Admiral’s Beach, Aquaforte, Biscay Bay, Branch, Brigus South, Calvert, Point Lance, Port Kirwan, Portugal Cove South, RenewsCappahayden, St. Bride’s, St. Joseph’s and Trepassey. The provincial government has established an Eastern Region Water Committee to assist communities with permanent solutions in addressing drinking water issues. Eastern Health participates on this committee. Environmental cleanup and remediation of former heavy industrial sites in the Southern Avalon (the former Argentia base and ERCO site in Long Harbour) has occurred through federal and provincial initiatives. Eastern Health was consulted throughout the process. Potential environmental issues related to proposed industrial development in the Long Harbour area (proposed Voisey’s Bay Nickel processing facility) and the crude oil refinery proposed for Southern Head are now under review in accordance with the requirements of the Canadian Environmental Assessment Agency and the provincial Department of Environment and Lands. Eastern Health participates in these reviews. In the telephone survey conducted as part of this community health needs assessment, 21% of respondents felt that water and sewer services were a major problem in their community, but only 6% felt that air or water pollution was a major problem. Housing A significant number of dwellings in the Southern Avalon are owned as opposed to being rented. (Based on 2001 census data, 91.4% of dwellings in Economic Zone 20 (Irish Loop) and 85.3% of dwellings in Economic Zone 18 (Avalon Gateway) are owned.70 Significant aging of the population coupled with out-migration means that a large number of seniors are living in homes that require repair. They often do not have the finances required to do the repairs, or family nearby to help.

“Who am I going to call when I need something repaired?” - Focus Group Participant

Newfoundland and Labrador Housing’s Provincial Home Repair Program provides a combination of grants and lowinterest repayable loans. This program is cost-shared (50/50) with the federal government and serves between 1800-2000 applicants per year (95% of them in rural areas of the province). Applicants are eligible for the program if they meet the income threshold (a family income of $32,000 or lower); approved applicants are served on a first-come, first-served basis. However, due to limited budgets and high volumes of approved applicants, there is a very long wait list (several years) for the service.

A review of clients served by this program indicates that between April 2000 and January 31, 2007, 389 clients from the Southern Avalon have received a grant or low-interest loan for home repairs (average of 55 clients per year). The current wait list indicates that approximately 168 people from the Southern Avalon region are waiting to access this program. Public rental housing units (86 units in the Southern Avalon - mainly in Placentia area) are available for people who meet the financial guidelines. Community-managed apartments are available in Trepassey, St. Joseph’s and St. Bride’s and Eastern Health manages cottages (40) located adjacent to the Health Centre in Placentia. Service reduction Rural communities, especially those experiencing declining populations, often have to deal with a withdrawal of services that are no longer considered viable in their area. They may also lose retail businesses as their population drops. This withdrawal of services was noted in several areas of the Southern Avalon, particularly the Placentia area. Key informants, focus group participants and telephone survey respondents noted several areas of concern. These include reduction in banking service (38% of telephone survey respondents noted the lack of financial services as a major problem for their community), the reorganization of Human Resources Labour and Employment programs to a telephone-access service, and reduced Provincial Court service in Placentia. The restructuring of local Roman Catholic parishes into clusters (with the subsequent reduction in local parish services) was also mentioned as an indicator of a decline in human resources and a dwindling parish population. Church halls, often the only public gathering space in the community, are getting more and more difficult to retain, given the associated costs. A common theme in discussions with focus group participants was the fear of losing more services. Those involved in municipal government referred to an eroding financial base that is making it very difficult to retain services, some of which are minimal in small rural communities. Declining school enrolments concern people in the Southern Avalon region. A comment often mentioned by key informants and focus group participants was: “We worry about what the future holds for our schools”. However, several communities in the Southern Avalon region are looking forward with anticipation to new or renovated school facilities - a new school in Mobile is under construction and a replacement for Laval School in Placentia is planned. Poor road conditions People who live in rural areas such as the Southern Avalon depend very much on road travel. Distances can be significant to access schools, grocery stores, the post office, the health clinic, secondary health services, churches and community events. If roads are in poor condition this makes travelling more difficult, and causes costly wear and tear on a person’s vehicle. In the telephone survey, 54% of respondents identified road conditions in the Southern Avalon as a “major problem” for their community. Poor road conditions, coupled with the fact that a large part of the Southern Avalon road system is located on exposed barrens, means that travelling is especially hazardous in winter (when blowing and drifting snow cause visibility problems) or in fog (which can occur at any time of the year). The road on the Cape Shore and the area around Trepassey can be particularly dangerous on stormy days.

Transportation and distance In addition to the challenge of road conditions, public transportation is somewhat limited in the area. There is no public transportation from Cape Shore communities to Placentia or from Placentia to Carbonear. Twenty-six percent (26%) of respondents to the telephone survey identified lack of public transportation as a major problem in their community.

While some communities on the Southern Avalon are relatively close to secondary health services available in St. John’s, some communities are more remote. Travel distances and estimated travel times from a selection of Southern Avalon communities are listed below.

Table 44: Distance and Driving Times, Selected Communities - Southern Avalon 71

DISTANCE

ESTIMATED DRIVING TIME at speed limit

St. Shott’s - St. John’s

161 km

2:16 (hrs/min)

Trepassey - St. John’s

147 km

1:51 (hrs/min)

St. Mary’s - St. John’s

115 km

1:37 (hrs/min)

Placentia - St. John’s

126 km

1:19 (hrs/min)

Branch - Placentia

64 km

0:39 (hrs/min)

St. Bride’s - Placentia

46 km

0:28 (hrs/min)

ROUTE

Source: NL Road Distance Database

8.7. Personal Health Practices and Coping Skills Individuals can take personal actions to promote and maintain their health. These include personal health practices such as getting regular exercise, eating a healthy diet, not smoking, using a seat belt and practicing safe sex. The actions a person takes to promote their own health can be very effective in preventing disease and helping one cope with lifeâ&#x20AC;&#x2122;s challenges. However, we now recognize that personal life choices are greatly influenced by the socioeconomic environments in which a person lives, learns, works and plays. Coping skills play a crucial role in how we handle stress in our lives and whether we develop dependencies on alcohol and other unhealthy supports.72 Findings Achieving Health and Wellness: Provincial Wellness Plan for Newfoundland and Labrador (Phase 1: 2006-2008) describes wellness priorities for the province.73 Many of these priorities address personal health practices and coping skills of individuals and encourage strategies for supporting positive personal health practices. The priorities that are receiving focus in phase one of the wellness plan are healthy eating, physical activity, tobacco control and injury prevention. Phase two will focus on mental health promotion, child and youth development, environmental health and health protection. Communities are getting involved in promoting activities to encourage positive personal health practices, and key informants and focus group participants were enthusiastic about these initiatives. They identified some community efforts that were underway to encourage improved personal health practices and healthy coping skills. Community Success Story - Personal Health Practices: The â&#x20AC;&#x153;Challenge Yourself â&#x20AC;? program operated out of the Father Val Power Centre in Riverhead in the fall and winter of 2006-07. The 16-week program saw participants setting personal goals to maintain or improve their health status, and provided encouragement through guest speakers, discussion groups and personal trainer support. Program organizers built incentives into the program - participants were given points for pounds and inches lost, for reducing their cholesterol or for quitting smoking. As an added incentive, the overall high point scorer won a trip to Montreal or Toronto. Local media coverage raised awareness of the issues of striving to keep fit and practice good health habits. Moving for Health groups were cited as another example of encouraging people to take action for improved health. These groups use existing community spaces, peer support and depend on community involvement. Several key indicators were examined during this needs assessment to better understand the personal health practices and coping skills/mechanisms of residents of the Southern Avalon. These indicators are measures of healthy eating, physical activity, body weight, and sexual health. Some coping mechanisms examined were smoking rates, alcohol and drug use and participation in gambling. Healthy eating can be challenging to measure. One method to measure healthy eating habits is to determine the daily level of consumption of fruits and vegetables. Respondents in the telephone survey were asked if they usually ate at least five servings of fruit and vegetables per day. Of the total sample for the region, 35% reported that they ate at least five fruits and vegetables per day. The detailed regional breakdown is reported in Table 45.

Table 45: Reported Consumption of Five Fruits and Vegetables Daily, Southern Avalon Telephone Survey Do you usually eat at least five servings of fruits and vegetables daily? REGION A Bay Bulls - Renews

REGION B Portugal Cove South - North Harbour

REGION C Branch - Long Harbour

Frequency

Percent

Frequency

Percent

Frequency

Percent

Yes

Donâ&#x20AC;&#x2122;t Know

122

100

103

100

140

100

Total

Twenty-five per cent (25%) of the total number of telephone survey respondents (365) noted that maintaining a healthy diet was a major problem in their community. Data from the Canadian Community Health Survey (2003) provides insight into a similar measure of fruit and vegetable consumption, but with a broader age category (12 years of age or older). Table 46 illustrates the percentage of the population aged 12 years and older in the Eastern Health region, the province of Newfoundland and Labrador, and the country, who reported consuming 5 to 10 fruits and vegetables a day.

Data source: Statistics Canada, Canadian Community Health Survey, 2003 74

Regular physical activity is essential to maintain and improve health. Physical activity rates were measured by asking telephone survey respondents about their participation in physical activities lasting 20 minutes or longer at least three times per week.

The response to this question indicates relatively high levels of participation in physical activity in the region. No significant variation in exercise could be detected between regions. Of the total number of respondents (365), 65% reported they participated in physical activities lasting 20 minutes or longer, at least three times per week. This compares to the Burin Peninsula telephone survey, where 66% reported participating in regular physical or recreation activities at least 2-3 times per week. Another measure for physical activity is found in the Canadian Community Health Survey (2003). It measured the percentage of the population aged 12 years and older who reported being active or moderately active. Data on this measure is not available for the Southern Avalon region. It may be easier to engage in physical activity if there is an organized program in the community or some place to go to play sports or get involved in a fitness program. Lack of recreational facilities was cited by 43% of telephone respondents as a major problem in their community; 29% felt that lack of recreational and social activities was a major problem.

Data source: Statistics Canada, Canadian Community Health Survey, 2003. 76

Maintaining a healthy body weight is another personal health practice that can have a significant impact on overall health. The Canadian Community Health Survey (2003) provides details on the percentage of the population 18 years and older who are overweight or obese.

Data source: Community Accounts, Health Accounts. (Statistics Canada, Canadian Community Health Survey, 2003) 77 * Confidence intervals are large due to small sample. ** Data suppressed due to confidentiality issues (small sample size).

Twenty-two per cent (22%) of telephone survey respondents considered obesity a major problem in their community.

Smoking rates were measured by asking telephone survey respondents about their smoking habits.

Of the 365 respondents to the telephone survey, 20% of them reported smoking cigarettes daily. This result can be compared to the Burin Peninsula telephone survey, where 24% of respondents reported smoking cigarettes daily.78 A slight (but not significant) trend was noted on the Southern Avalon between income and smoking. Lower income households tended to report smoking daily at a higher frequency than did households with higher incomes. The Canadian Community Health Survey (2003) provides some comparative data on daily smoking in the population, although age range of respondents (12 years and older) differs. Thirty-eight per cent (38%) of telephone survey respondents considered smoking to be a major problem in their community.

Data source: Community Accounts, Health Accounts. (Statistics Canada, Canadian Community Health Survey, 2003) 79 * Confidence interval is large due to small sample size. ** Data suppressed due to confidentiality issues (small sample size).

Sexual health includes taking actions to protect against sexually transmitted infections and unplanned pregnancies. Some key informants identified this as an issue, however, telephone survey respondents did not feel it was a major problem in the community. Teenage pregnancy and sexually transmitted diseases were regarded as â&#x20AC;&#x153;not a problemâ&#x20AC;? by 44% (teenage pregnancy) and 48% (sexually transmitted infections) of respondents to the telephone survey. It should be noted that approximately 15% of telephone survey respondents were between the ages of 19 and 39 years. Several key informants and focus group participants commented on the difficulty of maintaining anonymity and confidentiality in rural Newfoundland and Labrador when one is purchasing items such as condoms or seeking help and advice on sexual health issues. In 2004, the study Adolescent Sexual Decision-Making in Newfoundland and Labrador noted confidentiality issues as a concern of young people living in small rural communities, and recommended providing easy access to affordable birth control options.80 Lack of health services for teenagers was identified as a major problem in their community by 15% of telephone survey respondents. Twenty-three per cent (23%) of telephone respondents felt it was somewhat of a problem, 26% felt it was not a problem. Some efforts are being made through facilities such as the P4 Youth Centre (Placentia) to address healthrelated issues of teens and provide support groups and coping skills. Alcohol and drug use was mentioned by several key informants and focus group participants as an area of concern. Some people felt that frequent and heavy alcohol use was commonly accepted as integral to the culture of the region. Some key informants from Placentia and surrounding areas mentioned the negative legacy of inexpensive alcohol from the days of the American base. Several focus group members and key informants raised the issue of illegal drug use in their communities and identified it as a growing area of concern. Alcohol consumption patterns were measured by self-reporting; telephone survey respondents were asked about their alcohol consumption, on a weekly basis. Table 52 provides self-reported data on alcohol consumption patterns.

Seven per cent (7%) of the total number of respondents to the telephone survey (365) indicated that they consumed more than seven alcoholic drinks per week, on average. This compares with information from the Burin Peninsula Community Health Needs Assessment, where 9% of telephone respondents indicated they consumed this amount or more.81 There were no evident trends in alcohol consumption, either by region or by household income. Drunk driving was identified by 15% of telephone survey respondents as a major problem in their community, 33% thought it was somewhat of a problem, and 25% thought it was not a problem. Gambling was examined by asking telephone survey respondents how much money they spent on gambling per week, on average. For the purpose of the telephone survey, gambling was described as including purchase of scratch â&#x20AC;&#x2122;n win tickets, lottery tickets, break open tickets, video lottery terminals, card games or bingo. Eight per cent (8%) of respondents reported spending $20 or more on gambling ventures weekly.

There was no significant relationship between the respondentsâ&#x20AC;&#x2122; propensity to gamble and their location. No clear relationship could be established between gambling habits and household income. Seventeen per cent (17%) of telephone survey respondents identified gambling as a major problem in their community, 27% identified it as somewhat of a problem and 28% did not view gambling as a problem. The 2005 Newfoundland and Labrador Gambling Prevalence Study sampled 659 people in the Eastern Health region to determine a gambling prevalence rate of 87%.82 Lottery tickets were the most popular gambling activity in the Eastern Health region; it is estimated that 1.1% of gamblers in the Eastern Health region are problem gamblers.83

8.8. Healthy Child Development A personâ&#x20AC;&#x2122;s health, throughout their lifetime, is affected by the prenatal care received by their mother as well as the kinds of care they receive and experiences they have in their early childhood. The health of pregnant women and their readiness to provide a secure and happy environment for their baby is crucial to the later physical and mental health of their child. Income levels of mothers appear to be linked with the birth weight of the baby; low birth weights in turn link with problems in childhood and also in adulthood.84 Research recommends three broad areas of intervention as contributing to positive child outcomes: adequate income, effective parenting and supportive community environments.85

Findings Prenatal care in the Southern Avalon area is delivered through a variety of methods. Some pregnant women avail of Healthy Baby Clubs offered at Family Resource Centres and their satellite offices. In communities closer to St. John’s, some parents prefer to participate in the one-day weekend prenatal education session offered through the Women’s Health Centre. In other areas, such as Trepassey, the community heath nurse conducts one-on-one prenatal education sessions, as required. Prenatal education can also be tailored to the needs of clients who do not wish to attend group sessions. Participants in focus group discussions and key informants noted the importance of supporting pregnant women and families with young children, identifying this as a crucial time in establishing healthy practices and habits. Breastfeeding initiation is an important aspect of healthy child development. Breastfeeding initiation rates for the Southern Avalon indicate a low percentage of women who give birth are choosing this method of feeding their baby. Breastfeeding initiation rates fluctuate within the region, however, overall rates for the past four years are less than 36% of live births. The St. Mary’s area has the lowest rates of breastfeeding initiation. Family Resource Centres were highlighted as important sources of support to both pregnant women and families with young children. Family resource centres provide a wide range of needs-based family resource programs and are operated by an independent Board of Directors who are accountable for the programming. (Eastern Health’s role is one of financial oversight; one seat on the Board of Directors of the Family Resource Centre is reserved for an Eastern Health staff member.) Family Resource Centre programs are focused particularly on children up to the ages of 6 and are designed to promote self-help and mutual aid, enhance parent-child relationships and healthy prenatal and child development. Through Healthy Baby Clubs offered at the Family Resource Centre, pregnant women are provided with prenatal education and support; those on low incomes receive the Mother/Baby Nutrition Supplement to assist with the extra costs of eating healthy during pregnancy and throughout the child’s first year. The Healthy Baby Clubs also offer postnatal programs. There are two family resource centres serving the Southern Avalon Region. The Centre located in Placentia (Stepping Stones Family Resource Centre) also offers services in St. Bride’s and Mt. Carmel (as well as Whitbourne). The Kilbride to Ferryland Family Resource Centre offers services in Bay Bulls and Ferryland (as well as Kilbride and Goulds).

Table 54 describes the availability of service (hours open) offered by the Family Resource Centres in the Southern Avalon. Table 55 describes the program utilization at the different Family Resource Centres. Healthy Beginnings is a program designed to promote optimal physical, cognitive, communicative and psychological development in priority children. Follow-up to families is provided on a short- or long-term basis, based on a standardized screening tool. Table 56 describes the percentage of live births that were followed up on a longterm basis by the Healthy Beginnings program.

Day Care: In the Southern Avalon telephone survey, lack of day care options was cited as a major problem by 30% of respondents. This places it in the top seven issues identified as major problems which might be affecting the health and well-being of people in the community. Placentia has 16 licensed child care spaces; the Southern Shore area has 2 individual family child care licenses with the ability to accommodate 12 children.

8.9. Biology and Genetic Endowment The basic biology and organic makeup of the human body are significant determinants of health. Genetic endowment pre-disposes certain individuals to develop particular diseases or health problems. However, aging should not be viewed as synonymous with developing poor health.86 Findings Like other areas of the province of Newfoundland and Labrador, the Southern Avalon has a number of inherited diseases that are present in the area. These include three types of hereditary cancers: ◆ gastric cancer (for which the genetic mutation has been identified and testing is possible, although it is difficult to identify the condition until it is fairly well advanced) ◆ breast cancer (where the genetic mutation is known and testing is possible) ◆ colon cancer (where the genetic mutation has been identified but testing is difficult and costly) In addition, there are several other inherited diseases that occur in the Southern Avalon region including polycystic kidney disease (testing for this condition is difficult and expensive), Batten’s disease (an early onset neurodegenerative disorder that occurs in early childhood - genetic testing is possible for this condition) and a cone dystrophy disease of the eyes which causes central vision loss (the gene is not known for this condition).87

8.10. Gender and Culture Gender refers to the many different roles, attitudes, behaviours, values and relative power and influence that society assigns to the two sexes. Each gender has specific health issues, or may be affected in different ways by the same issues. Gender roles and biases shape behaviours that may promote or damage health. Gender discrimination may prevent equitable access to other health determinants (income, employment, etc.). Cultural roles and biases may create stereotypes that influence physical or mental well-being.88 Findings Gender-related health issues and participation rates in particular screening programs (such as cervical screening, breast cancer screening and prostate cancer screening) were discussed by some key informants and focus group participants. They spoke positively of the Well Women and Well Men Clinics held in the area that have focused on increased participation in screening (cervical, breast and prostate cancer) as well as the Rural Women’s Health Days that encourage women to take a proactive role in promoting their health. They see these initiatives as excellent ways to encourage men and women to look after health needs particularly related to their sex, in a supportive and encouraging environment. Breast examinations. As part of the Southern Avalon telephone survey conducted for this community health needs assessment, female respondents were asked when they had last had a breast exam by a doctor or a nurse. Sixteen of the 275 female respondents reported never having had a breast exam, 11 of these were located in Region C (Branch to Long Harbour).

Mammograms. Thirty-two per cent (32%) of telephone respondents reported never having had a mammogram (35% in Region A: Bay Bulls to Renews; 23% in Region B: Portugal Cove South to North Harbour and 38% in Region C: Branch to Long Harbour). Since a significant percentage of the telephone survey respondents were female (75%) and 63% of them were over 50 years of age, this would suggest that low numbers of females over the age of 50 are having mammograms, contrary to recommended screening guidelines. Cervical Screening. A total of 63% of respondents reported that they had been screened for cervical cancer (had a pap smear) within the past three years. This compares to 65% of the Burin Peninsula telephone survey respondents who reported that they had been screened for cervical cancer in the past three years.89 Currently, provincial guidelines recommend annual cervical screening; 45% of telephone respondents reported having had a pap test in the past year. While no formal surveillance data was available for the geographic area covered by the Southern Avalon Needs Assessment, Rural Avalon data (this includes the Placentia and St. Mary’s areas) indicates that 31% of women aged 15-70 had a pap test in 2005. Women’s wellness initiatives in Placentia and St. Mary’s in the past year have focused on increasing the numbers of women having annual pap tests. Recently, additional human resources to promote cervical screening have been added in the St. John’s area of Eastern Health, including coverage for the Southern Shore area. Table 58 describes the telephone survey responses regarding frequency of pap tests.

Prostate Cancer Screening. Thirty-three per cent (33%) of male telephone survey respondents indicated they had never been checked by a doctor for prostate cancer. Fifty-six per cent (56%) of those who reported having the test, indicated having the procedure within the last year.

Initiatives that support and empower genders are important. Communities can take steps to encourage healthy gender relationships among young people and develop self-esteem. The P4 Centre in the Placentia area promotes this concept through local programs (example Girl Matters: for girls ages 14-16). Rural Womenâ&#x20AC;&#x2122;s Health Days, Well Men and Well Women Clinics all play a positive role in supporting health related to gender.

8.11. Conclusions - Determinants of Health Many of the determinants of health that have been discussed in Section 8 are related to the challenges of living in a predominately rural area. In its 2006 report How Healthy are Rural Canadians? the Canadian Population Health Initiative examines the role of place in determining health. They conclude that rural communities generally are less healthy than their urban counterparts.90 Socio-economic factors are noted as important indicators, with rural residents more likely to report low incomes. Personal health practices (dietary practices, lower leisure time physical activity levels and higher smoking rates) were also noted as significant issues in rural areas. On the positive side, rural residents reported a greater sense of community belonging and were less likely to report high levels of stress.

9. Eastern Health - The Organization Throughout the needs assessment process several key issues, related directly to the way Eastern Health is organized and conducts its key business, were identified repeatedly. These are: ◆ There needs to be consistency in programs and policies of the organization. ◆ Eastern Health needs to communicate effectively with the public (in terms of navigating the health system). ◆ Management of information is a challenging process and some Eastern Health systems are inadequate. ◆ Eastern Health staff need core skills in collaborating and partnering with the people who receive our service (clients, patients, residents, families), internal and external partners and the community. ◆ We need to support and partner with communities and other external partners in moving forward “on the path to health and wellness”.

9.1. Recommendations 1. Communicate the results of the Southern Avalon Community Health Needs Assessment broadly to the public, key informants, focus group participants, Eastern Health staff and physicians, and key partners. 2. Provide the Board of Trustees of Eastern Health with a semi-annual written status report regarding progress on implementation of the recommendations. 3. Provide the public with a status report, two years from the release date of the Southern Avalon Community Health Needs Assessment, regarding progress on implementation of recommendations of this report. 4. Develop a systematic executive-level plan to review, and, where necessary, revise Eastern Health’s policies and programs to ensure consistency in provision of programs and services across the region. 5. Implement a mechanism(s) throughout the Eastern Health region to ensure Eastern Health programs and services are communicated in a user-friendly and accessible way to the public (including clients, patients, residents and families), our partners and our staff. Investigate feasibility of the following options: i. 1-800 telephone system serving the entire Eastern Health region supported by accessible database of services/forms/program data. ii. Web-based information system (services/forms/program data) accessible to the public, partners and staff. (Modelled on 1-800-O Canada)

6. Request that the Information Management Committee of Eastern Health develop a plan to improve the integrity and integration of the community-based management information systems. 7. Enhance capacity of Eastern Health staff to work effectively with individual and community partners through the development of targeted education and training opportunities. 8. Identify ways to mutually strengthen and support the partnership between Family Resource Centres and Eastern Health. 9. Advocate with external partners for continued implementation of the provincial governmentâ&#x20AC;&#x2122;s Poverty Reduction Strategy (Reducing Poverty: An Action Plan for Newfoundland and Labrador, June 2006.) 10. Establish mechanisms for working partnerships with the education system (Eastern District School Board, Department of Education), the justice system (RCMP, court system), and Human Resources Labour and Employment (HRLE).

10. Conclusion The Southern Avalon Community Health Needs Assessment has given Eastern Health an opportunity to learn about the needs of the area. We have had a dialogue with community members about the challenges to health and wellness in the region and have discussed some potential solutions. Communities have offered ideas and want positive change - they are moving forward with strategies that are making a difference. Eastern Health has a responsibility to partner with communities in responding to the challenges identified in this community health needs assessment and supporting activities â&#x20AC;&#x153;on the path to health and wellness.â&#x20AC;? We commit to this challenge and look forward to this partnership.

Endnotes 1

Statistics Canada (2007) Population and Dwelling Count Highlight Tables, 2006 Census, released March 13, 2007. Accessed March 13, 2007 at http://www12.statcan.ca/english/census06/release/release_popdwell.cfm

Chinook Health Region, Alberta (1998). Developing Healthy Communities.

Statistics Canada (2007)

Cavanagh, S. and Chadwick, K. (2005) Summary: Health Needs Assessment. Health Development Agency, p. 7

Cavanagh, S. p. 2

Eastern Health (2006). Navigating the Way Together: Burin Peninsula Community Health Needs Assessment.

Cavanagh, S. pp. 20-22

WHO. Definition of Health. Accessed December 14, 2006 at http://www.who.int/suggestions/faq/eng/

Public Health Agency of Canada. Population Health. Accessed December 14, 2006 at http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants

Health Canada. (2001). Achieving Health for All: A Framework for Health Promotion. Accessed December 14, 2006 at http://www.hc-sc.gc.ca/hcs-sss/pubs/care-soins/2001-frame-plan-promotion/index-e.html

Public Health Agency of Canada. Population Health. Accessed December 14, 2006.

Eastern Health p. 8.

Calculated from Newfoundland and Labrador Community Accounts, Newfoundland and Labrador Demographic Accounts. Accessed February 12, 2007 at http://www.communityaccounts.ca/communityaccounts/onlinecata/table_d7r.asp?comval=prov&whichacct=demographic.

Eastern Health p. 8.

Calculated from Statistic Canada - Community Profiles. Accessed February 12, 2007 at http://www12.statcan.ca/english/profil01/CP01/Details/Page.cfm?Lang=E&Geo1=PR&Code1=10&Geo2=PR&Code2=01& Data=Count&SearchText=Newfoundland%20and%20Labrador&SearchType=Begins&SearchPR=01&B1=All&GeoLevel=& GeoCode=10.

Health and Community Services Eastern (2002), Health in our Community.

Memorial University of Newfoundland and Health and Community Services, St. Johnâ&#x20AC;&#x2122;s Region (2001), A Summary Report on the Community Health Needs and Resources Assessment of the St. Johnâ&#x20AC;&#x2122;s Region.

Government of Newfoundland and Labrador, NL Statistical Agency. Community Accounts. Accessed December 8, 2006 at http://www.communityaccounts.ca

Statistics Canada (2007)

Community Accounts, Economic Zone 20 Demographic accounts. Accessed December 11, 2006 at http://www.communityaccounts.ca

Statistics Canada (2007)

Government of NL, Department of Finance, Economics and Statistics Branch. Population Projections. Accessed January 12, 2007 at http://economics.gov.nl.ca/population/byage-ZONE.asp

Community Accounts, School Accounts. Accessed January 9, 2007 at http://www.communityaccounts.ca/communityaccounts/onlinedata/schools.asp?type+schools

Statistics Canada (2007)

Government of NL, Department of Finance, Economics and Statistics Branch, Population Projections. Accessed January 16, 2007.

Community Accounts, School Accounts. Accessed January 16, 2007.

Government of NL, Department of Finance. Economics and Statistics Branch. Population Projections. Accessed January 16, 2007.

Government of NL, Department of Finance, Economics and Statistics Branch, Population Projections. Accessed January 16, 2007.

Government of NL, Department of Tourism: Scenic Touring Routes. Accessed December 11, 2006 at http://www.newfoundlandlabrador.com/PlacesToGo/ScenicTouringRoutes.aspx

Voiseyâ&#x20AC;&#x2122;s Bay Nickel Company, Project Description. Accessed January 15, 2007 at http://www.vbnc.com/Processing.asp

Community Accounts. Well-Being Indicator Analysis. Accessed February 9, 2007 at http:www.communityaccounts.ca/communityaccounts/onlinedata/indicatoranalysis.asp?

Public Health Agency of Canada. Chronic Disease. Accessed March 20, 2007 at http://www.phac-aspc.gc.ca/ccdpc-cpcmc/topics/chronic-disease_e.html

Diabetes Care in Canada: Results from Select Provinces, 2005 (CCHS Cycle 3.1)

Canadian Institute of Health Information (CIHI). Beyond DMG and Plx: ELOS and RIW, Fiscal 2001, p. 2

Public Health Agency of Canada. Chronic Disease. Accessed March 20, 2007.

Department of Health and Community Services, Eastern Health Provincial Cancer Program, Canadian Cancer Society, 2006. Gaining Ground: A Cancer Control Strategy for Newfoundland and Labrador, p. 3

Eastern Regional Health Authority (2006) Strategic Plan, p. 12

Eastern Regional Health Authority (2006) p. 13

Government of Newfoundland and Labrador, Department of Health and Community Services. Achieving Health and Wellness: Provincial Wellness Plan for Newfoundland and Labrador (Phase 1:2006-2008). Accessed March 20, 2007 at http://www.health.gov.nl.ca/health/publications/2006/wellness-document.pdf

Eastern Health p. 86

Canadian Institute for Health Information (2006) Health Indicators, p. 42

Eastern Health (July 2006). Working Together for Mental Health: A Regional Action Plan, p. 3

Public Health Agency of Canada. Population Health Approach - What Determines Health? Accessed January 6, 2007 at http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/determinants.html

Community Accounts. Regional Profiles. Accessed January 20, 2007 at http://www.communityaccounts.ca/communityaccounts/onlinedata/communityprofile

Community Accounts. Accessed January 20, 2007.

Eastern Health p. 34.

Statistics Canada. Persons in low income before tax, by prevalence in percent (2000 to 2004). Accessed February 12, 2007 at http://www40.statcan.ca/l01/cst01/famil41a.htm.

Eastern Health p. 34.

Roebothan, Barbara V (2003). Nutrition Newfoundland and Labrador: The Report of a Survey of Residents of Newfoundland and Labrador, 1996. St. Johnâ&#x20AC;&#x2122;s, NL , Department of Health and Community Services, Province of Newfoundland and Labrador, pp. 13-14

Dietitians of NL, NL Public Health Association, NL Association of Social Workers (2004). The Cost of Eating in Newfoundland and Labrador - 2003, p. 9

The Charter, March 19, 2007. Nutrition Month, But Not For Some. p. 3

Public Health Agency of Canada. Population Health Approach - What Determines Health? Accessed January 6, 2007.

Community Accounts, Production Accounts, Business Register. Accessed February 18, 2007 at http://www.communityaccounts.ca/communityaccounts/onlinedata

Community Accounts, Labour Market Accounts. Accessed February 18, 2007 at http://www.communityaccounts.ca/communityaccounts/onlinedata/

Community Accounts, Labour Market Accounts. Accessed February 18, 2007.

Community Accounts, Social Accounts. Retrieved February 19, 2007 at http://www.communityaccounts.ca/communityaccounts/onlinedata

Public Health Agency of Canada. Population Health Approach - What Determines Health? Accessed January 28, 2007.

Community Accounts, Well-being Indicator Analysis. Accessed March 6, 2007.

Newfoundland and Labrador Statistical Agency. Population Projections, Newfoundland and Labrador, Medium Scenario. Accessed March 7, 2007 at http://www.economics.gov.nl.ca/population/

Public Health Agency of Canada. Population Health Approach - What Determines Health? Accessed January 28, 2007.

Community Accounts, Education Accounts. Accessed January 30, 2007 at http://www.communityaccounts.ca/communityaccounts/onlinedata

Community Accounts, Education Accounts. Accessed January 30, 2007.

Public Health Agency of Canada. Population Health Approach - What Determines Health? Accessed January 28, 2007.

Community Accounts, Household Spending Accounts. Accessed January 30, 2007 at http://www.communityaccounts.ca/communityaccounts/onlinedata

Government of NL, Works Services and Transportation. Road Distance Database. Accessed February 20, 2007 at <http:www.stats.gov.nl.ca/DataTools/RoadDB/Default.asp>

Public Health Agency of Canada. Population Health Approach - What Determines Health? Accessed January 28, 2007.

Government of Newfoundland and Labrador, Department of Health and Community Services Achieving Health and Wellness: Provincial Wellness Plan for Newfoundland and Labrador.

Newfoundland and Labrador Centre for Health Information, Research and Development Division (2006). Survey Says: A Report on Selected Health Indicators: Canadian Community Health Survey 2003, p. 8

Eastern Health p. 65

Newfoundland and Labrador Centre for Health Information, Research and Development Division (2006), p. 7

Community Accounts, Health Accounts. Accessed March 7, 2007 at http://www.communityaccounts.ca/communityaccounts/onlinedata

Eastern Health p. 63

Community Accounts, Health Accounts. Accessed March 7, 2007.

Planned Parenthood of Newfoundland and Labrador (now the NL Sexual Health Centre) and Womenâ&#x20AC;&#x2122;s Health Network, Newfoundland and Labrador. (2004) Adolescent Sexual Decision Making in Newfoundland and Labrador.

Eastern Health p. 64

Government of Newfoundland and Labrador, Department of Health and Community Services. (2005) Newfoundland and Labrador Gambling Prevalence Study, p. 19

Government of Newfoundland and Labrador, Department of Health and Community Services. (2005) Newfoundland and Labrador Gambling Prevalence Study, p. 43

Public Health Agency of Canada. The Determinants of Health. Accessed March 8, 2007 at http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/determinants.html#healthychild

Canadian Institute for Health Information, Canadian Population Health Initiative (2004). Improving the Health of Canadians, p. 55

Public Health Agency of Canada. The Determinants of Health. Accessed March 8, 2007 at http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/determinants.html#genetic

Data in section 8.9 is based on a telephone interview with Dr. Jane Green, Professor of Medical Genetics, Faculty of Medicine, Memorial University of Newfoundland.

Public Health Agency of Canada. The Determinants of Health. Accessed March 8, 2007 at http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/determinants.html#genetic

Eastern Health p. 75

Canadian Population Health Initiative. September 2006. Summary Report: How Healthy are Rural Canadians?: An Assessment of their Health Status and Health Determinants, p.9. Accessed March 22, 2007 at http://secure.cihi.ca/cihiweb/products/summary_rural_canadians_2006_e.pdf

Terms of Reference Steering Committee

Terms of Reference Community Health Needs Assessment Steering Committee 1.0 Purpose The Committee will oversee the community health needs assessment for the Southern Avalon Region. 2.0 Duties The duties of the Committee are to: 2.1 Oversee the development of a community health needs assessment plan. 2.2 Seek advice from the Community Health Needs Assessment Advisory Committee. 2.3 Review and provide feedback on the primary and secondary research findings of the community health needs assessment and the draft report. 2.4 Approve the community health needs assessment results. 2.5 Evaluate the community health needs assessment process. 3.0 Membership The Committee will be chaired by Wayne Miller, Senior Director, Corporate Strategy and Research. The Chair will report to the CEO on the activities of the Committee. The Committee will include the following people: Wayne Miller, Senior Director, Corporate Strategy and Research. Laura Woodford, Manager, Strategic Communications Natalie Moody, Director, Health Promotion Judy Power, Director, Primary Health Care Mary Rossiter, Social Worker, Community Living and Supportive Services (Southern Shore) Bertha Butler, Community Health Nurse (Trepassey) George Andrews, Mental Health Counsellor (Southern Shore) Sandra Gear, Primary Health Care Project Coordinator (Placentia area) Marian Mooney, Community Health Nurse (St. Bride’s) Doris Lewis, Manager, Community Health Nursing, Rural Avalon Janice Dalton, Manager, Allied Health and Community Supports (Seniors) Rural Avalon Jane Macdonald, Planning Specialist Ex-officio members include: Fay Mathews, Chief Operating Officer, Rural Avalon Bev Clarke, Chief Operating Officer, Community, Children, Mental Health and Addictions Alice Kennedy, Chief Operating Officer, Long Term Care and Supportive Services Lisa Browne, Planning Specialist

4.0 Meeting The Committee shall meet every 4-6 weeks, or at the call of the chair, until the completion of the assessment. 5.0 Quorum A majority (50% plus 1) of all members shall constitute a quorum.

Terms of Reference Advisory Committee

Terms of Reference Community Health Needs Assessment Advisory Committee 1.0 Purpose The purpose of the Community Health Needs Assessment Advisory Committee is to provide advice and feedback on the Southern Avalon Community Health Needs Assessment to the Community Health Needs Assessment Steering Committee of Eastern Health. 2.0 Duties The duties of the Community Health Needs Assessment Advisory Committee are to: 2.1 Act as a resource to the Community Health Needs Assessment Steering Committee on the Southern Avalon Needs Assessment. 2.2 Serve as a mechanism to exchange ideas related to the Southern Avalon Community Health Needs Assessment. 2.3 Respond to questions from the Community Health Needs Assessment Steering Committee. 3.0 Membership The committee shall consist of persons representing organizations that shape the health of individuals and communities (Health Canada’s determinants of health). The committee will be facilitated by Wayne Miller or Jane Macdonald who will be responsible for calling the meetings. The facilitator will report to the Health Needs Assessment Steering Committee. Membership shall include, but not be limited to, representatives from the following areas:

Employment & Working Conditions Education Social Support Networks Income and Social Status Physical Environment Healthy Child Development Seniors Youth and Teens

4.0 Meetings The committee shall meet a maximum of five times during the course of the needs assessment. The initial meeting will be to update the committee on the needs assessment plan. Subsequent meetings will be called to exchange ideas and update the Advisory Committee about the progress of the needs assessment. A concluding meeting will present the results of the needs assessment. 5.0 Quorum A majority (50% plus 1) of all members shall constitute a quorum.

List of Key Informants

Key Informants Dr. A. Al-Kadini, Physician, Shamrock Clinic, Ferryland Dr. F. Ali, Physician, Shamrock Clinic, Ferryland Staff Sergeant Ron Andrews, RCMP Avalon District, Holyrood Corey Banks, Division Manager, Paramedicine and Medical Transport Catherine Barker-Pinsent, Director, Child Youth and Family Services, Rural Avalon Staff Sergeant Dave Bishop (acting), RCMP, Placentia Detachment Bertha Butler, Community Health Nurse, Trepassey George Butt, Vice-President, Corporate Services Ken Carter, Regional Partnership Planner – Avalon Region, Rural Secretariat, Carbonear Darrel Clarke, Administrator, Placentia Campus, College of the North Atlantic Felix Collins, MHA, District of Placentia-St. Mary’s Priscilla Corcoran-Mooney, Facilitator, Placentia Primary Health Care renewal project Derrick Curtis, Development Officer, Irish Loop Regional Economic Development Board Marilyn Curtis, Executive Director, Southern Avalon Development Association and former mayor, Town of Trepassey Dr. H. Demien, Physician, formerly of St. Mary’s and Mt. Carmel Noreen Dort, former Director, Primary Health Care Gail Downing, Director of Integrated Health Services, Institutions, Rural Avalon Sandra Gear, former Coordinator, Placentia Primary Health Care renewal project Fr. Peter Golden, Parish Priest, Trepassey Rosemary Houlihan, Acting Vice-Principal, Mobile School, Mobile Tom Kennedy, Pharmacist, Bay Bulls Dr. B. Mangat, Senior Medical Officer, Placentia Health Centre Ann Manning, Director, Community Health and Nursing Services Calvin Manning, CEO, Avalon Gateway Regional Economic Development Board Dr. T. McGarry, Physician, Trepassey Diane Molloy, Executive Director, Foster Families Association of NL

100

Marian Mooney, Community Health Nurse, St. Bride’s Dan O’Brien, Pharmacist, Ferryland Judy O’Keefe, Director of Integrated Health Services, Long Term Care and Supportive Services, Rural Avalon Moira O’Regan-Hogan, Community Health Nurse, Witless Bay Jacqueline Pennell, Pharmacist, Trepassey Kate Pennell, Development Officer, Irish Loop Regional Economic Development Board Cathy Perry, CEO, Celtic Business Development Corporation, Ferryland Jennifer Phillips, Guidance Counsellor, Baltimore School, Ferryland Dana Pittman, Rural Partnership Planner-Avalon Region, Rural Secretariat, Placentia Fr. Pat Power, Parish Priest, Bay Bulls and Witless Bay Don Regular, Board Chair, Trinity-Conception-Placentia Foundation Diane Reid, Facility Manager, Placentia Health Centre Betty Reid-White, Director of Integrated Health Services, Community Health, Rural Avalon Dr. Tony Rockel, Physician, Placentia Todd Squires, Pharmacist, St. Mary’s Loyola Sullivan, MHA (former), District of Ferryland Margot Suttis, Manager, Community Health and Nursing Services (Southern Shore) Fr. Ed Sutton, Parish Priest, Brigus South to Cappahayden Fr. Declan Thompson, Parish Priest, St. Bride’s

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Standardized Questionnaire Used to Guide Key Informant Interviews

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Standardized Questionnaire Used to Guide Key Informant Interviews 1. What do you consider to be the main strengths and challenges of this region? 2. Regarding the determinants of health (show list) what do you consider the most important issue (determinant) that needs to be addressed in this region? 3. Overall, what do you consider to be the main health concern(s) of this region? In your opinion, how can these health concerns be reduced or eliminated? 4. I would like you to reflect on some particular age groups now. I would like your opinion about what you feel are the main health-related concerns for the following age groups in this region. To what extent are these needs being met? What suggestion do you have for meeting these needs? (Pre-school children, school-age children, adolescents, adults, seniors). 5. In your opinion, what would need to happen in order for the people of this region to achieve an optimal state of health? 6. What do you think this region will look like 10-15 years from now? What would you like it to look like? What will it take to bridge the gap? 7. Of all the concerns we discussed here today, what is the one issue that is the most important to address? 8. Have we missed anything that you would like to comment on regarding the health-related needs of this region? Do you have any other concerns regarding the health needs of the region that you would like to note? 9. Is there a particular person, or group that you feel I should consult during the needs assessment?

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Representatives/Organizations Invited to Attend a Focus Group Session

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Southern Avalon Community Health Needs Assessment – Focus Groups 1 2 3 4 Partners, Southern Shore Health Services Providers, Community Advisory Community Advisory Committee, Primary Health Care Committee, Primary Health Care Southern Shore - St. Mary’s Bay (plus additional – Placentia Nov. 15, 2006, 2 p.m. Nov. 14, 2006, 2 p.m. invited community members) Colony of Avalon Colony of Avalon Nov. 6, 2006, 7 p.m. Nov. 1, 2006, 3 p.m. Ferryland Ferryland Town Hall, St. Mary’s Multipurpose Room, Placentia Health Centre Participants invited Participants invited Participants invited Participants invited Committee members Committee members representing Mental Health and Addiction Irish Loop Regional Economic representing the following the following Counsellor Development Board groups/organizations: groups/organizations: representative Town of Branch Town of St. Mary’s * Community Health Nurses (3 Celtic Community Business invited – Witless Bay, Ferryland Development Corporation, Trepassey) * (1 in attendance) Employment Counsellors (2 invited, Trepassey and Ferryland) Fox Harbour Museum Town of Peter’s River Lab/X-ray Technician RCMP (2 invited, Trepassey and Ferryland) * (1 attended) Recreation Committee, Cuslett * Town of St. Vincent’s Social Worker, Community Principal or designate, St. Supports * Bernard’ s School, Witless Bay Clergy Town of St. Joseph’s * Social Worker, Child Youth and Vice-Principal or designate, Family Services Mobile Central High, Mobile Dept. of Industry, Trade and Rural Seniors’ Group, Pt. LaHaye Child Care Services Manager Guidance Counsellor or Development designate, Baltimore School, Ferryland Family Resource Centre * Fr. Val Power Centre, Riverhead * Clerical Support staff person Principal or designate, Stella Maris School, Trepassey Girl Guides * Community Volunteer * Clowe’s Ambulance Service Family Resource Centre (Ferryland) representative P4 Youth Centre * Pharmacist, St. Mary’s * Emergency Medical Service, Human Resources Labour and Renews Employment - Program Supervisor *

106 Mayor/designate, O’Donnell’s

RCMP

* Attended Focus Group Meeting

Mayor/designate, Admiral’s Beach

Laval High School

St. Mary’s Bay Centre Regional Development Association * Community Volunteer *

Family Resource Centre *

50+ Club representative

Mayor/designate, North Harbour Lion’s Club representative

Mayor/designate, Mt. CarmelMitchell’s Brook-St. Catherine’s Mayor/designate, Colinet

Walsh’s Personal Care Home, Bay Bulls Dinn’s Complex for Seniors, Witless Bay Fahey’s Personal Care Home, Fermeuse Ocean View Rest Home, Trepassey Quality Home Care Agency * Gina’s Family Home Day Care, Bay Bulls Forever Young Day Care, Cape Broyle Alternate Family Home caregiver, Southern Shore

Probation Officer, Adult Corrections *

Southern Avalon Community Health Needs Assessment – Focus Groups 2 3 4 Ryan’s Ambulance Service, Human Resources, Labour and Other invited participants Trepassey Employment, Liaison Social included: Workers ** (2 attended)

Regional Economic Development Board (Avalon Gateway) St. Anne’s Academy *

1 Genesis Employment *

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Dr. E. Elbarasi Dr. A. Rockel Dr. R. Penney

Trepassey Area Health Care Association Knights of Columbus, Witless Bay

Kinsman Club, Witless Bay

Women’s Institute, Ferryland Portugal Cove South Heritage Committee Colony of Avalon Southern Shore Folk Arts Council* Trepassey Recreation Committee Rural Secretariat Avalon Region volunteer members from Bay Bulls, Trepassey and Calvert Fermeuse/Pt. Kirwan Volunteer Fire Department Ferryland Recreation Committee Citizen’s Against Crime, Calvert

* Attended Focus Group Meeting

Dr. N. Belgasem *

Irish Loop RED Board representative *

Others in attendance: Council members, St. Shott’s (4) * Town Clerk, St. Shott’s * Council member, St. Vincent’sSt. Stephen’s-Peter’s River *

Mayor or designate, St. Vincent’sSt. Stephen’s-Peter’s River * Mayor or designate, Gaskiers-Pt. LaHaye Mayor or designate, St. Mary’s Mayor or designate, Riverhead

Mayor or designate, St. Shott’s *

Mayor or designate, Trepassey *

Representative, Angel’s Cove Representative, Ship Harbour

Mayor or designate, Point Lance

Mayor or designate, Fox Harbour *

Mayor or designate, Long Harbour-Mt. Arlington Heights Mayor or designate, Branch

Southern Avalon Community Health Needs Assessment – Focus Groups 6 7 8 Placentia area physicians Municipal leaders (Joint Municipal leaders – Placentia Council) Southern Avalon-St. and area Nov. 16, 2006, 1 p.m. Mary’s Bay Conference Room Nov. 20, 2006, 12 p.m. Placentia Health Centre Nov. 16, 2006, 7 p.m. Star of the Sea Hall, Placentia St. Shott’s Community Hall Participants invited Participants invited Participants invited Dr. B. Mangat * Mayor or designate, Portugal Mayor or designate, Placentia * Cove South Dr. Ilo de Porres * Mayor or designate, Biscay Bay Mayor or designate, Branch *

Trepassey Seniors Peer Advocates Fermeuse/Renews Girl Guides

Participants invited Irish Loop 50+ Association

Nov. 15, 2006, 7 p.m. Colony of Avalon, Ferryland

5 Community Groups, Southern Shore

108 Placentia Area Development Association Placentia Area Lions Club

Community Health Nurse, Placentia

Community Health Nurse, St. Bride’s Licensed Practical Nurse PHC *

St. Anne’s Knights of Columbus Freshwater Community Centre Festival of Flags * Bay TV Women’s Institute Dunville * (2) Seniors’ Club, Freshwater

Nurse Practitioner, PHC *

Social Worker, PHC

Registered Dietician, PHC

Recreation Therapy Worker, PHC*

Occupational Therapist, PHC *

Physiotherapist, PHC *

Placentia Volunteer Fire Department

Nov. 20, 2006, 7 p.m. Placentia Senior Citizens Club, Placentia Participants invited Fox Harbour Recreation Committee Senior Citizen’s Club, Jerseyside

Principal/designate, Fatima Academy St. Bride’s Executive Director/ designate, Argentia Chamber of Commerce

Corrections and Community Services representative * (2) Service Canada representative

Nov. 21, 2006, 1:30 p.m. Star of the Sea Hall Placentia Participants invited Principal/designate Laval High School Human Resources, Labour and Employment Client Services Officer * Human Resources, Labour and Employment, Liaison Social Workers (2) * Principal/designate, St. Anne’s Academy CEO/designate, Avalon West Community Business Development Corporation RCMP Staff Sergeant – Placentia Detachment Coordinator, Victim Services *

Social Worker, Youth Services and Community Corrections Social Worker, Child Youth and Family Services Manager of Community Health *

Social Worker, Community Supports * Social Worker, Foster Care *

Mental Health Counsellor *

Laboratory Assistant, St. Mary’s/Mt. Carmel Receptionist, St. Mary’s Clinic *

Nurse Practitioner, St Mary’s/Mt. Carmel *

Participants invited Community Health Nurse, St. Joseph’s * Community Health Nurse, St. Mary’s

Nov. 29, 2006, 10:30 a.m.

Southern Avalon Community Health Needs Assessment – Focus Groups 10 11 12 Community organizations, Partners, Placentia area Health Services Providers, St. Placentia and area Mary’s Bay area

Nov. 20, 2006, 2 p.m. Multipurpose Room, Placentia Health Centre Participants invited Nurse Manager, Placentia Health Centre/Lions Manor (PHC) * Registered Nurse, PHC

9 Health Services Providers, Placentia and area

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Southern Avalon Community Health Needs Assessment – Focus Groups 10 11 12 Sports and Recreation Gibbons Ambulance Services * Commission, Long Harbour Seniors’ Club, Long Harbour Lewis’ Personal Care Home Rural Secretariat members, Best of Care Agency Avalon Region (2) Dunville Auxiliary * Alternate Family Caregiver Lions Club also attended: Town of Placentia representative *

* Attended Focus Group Meeting

X-ray and Lab technician * Health Records Pharmacists (community) - 2 Power’s Ambulance, Placentia Cape Shore Ambulance Gateway Personal Care Home Caregivers Home Support Agency Alternate Family Home Caregiver Child Care Services Manager Behaviour Management Specialist * Social Worker, Community Supports * Child Management Specialist *

9 Social Worker, Child Youth and Family Services Mental Health Counsellor Addictions Counsellor

110 St. Joseph’s representative * (2)

O’Donnell’s representative

Mt. Carmel representative * Colinet representative *

North Harbour representative Forest Field/Newbridge representative Harricott representative

Mayor or designate, Witless Bay Mayor or designate, Cape Broyle Mayor or designate, Ferryland * (2) Mayor or designate, Port Kirwan Mayor or designate, Fermeuse * (2) Mayor or designate, Renews-Cappahayden * (2) Mayor or designate, Aquaforte Irish Loop RED Board * (2)

Southern Avalon Community Health Needs Assessment – Focus Groups 14 15 16 Municipal Leaders (North Seniors Municipal Leaders, Harbour to Admiral’s Southern Shore (Joint Beach) Council) Nov. 30 2006, 1:30 p.m. Nov. 29, 2006, 7 p.m., RED Board office Nov. 39, 2006, 7:30 p.m. St. Joseph’s Town Hall Trepassey Renews Town Hall Participants invited Participants invited Participants invited Admiral’s Beach Trepassey 50+ Seniors’ Mayor or designate, Bay representative * (2) Club representatives * (3) Bulls

* Attended Focus Group Meeting

Regional Director, Health Promotion * Regional Nutritionist * (3) Child Health Coordinator *

Health Promotion Wellness Consultant * Wellness Consultant *

School Health Coordinator * Parent and Child Health Coordinator * Health Educator *

Dietitian *

Nov. 29, 2006, 2 p.m. Hawco Building, Holyrood Participants invited All health promotion consultants

13 Health Promotion Consultants, Eastern Health

Feb. 8, 2007, 3:30 p.m. P4 Youth Centre Participants invited Youth who use P4 facilities, who were interested in topic and who provided (and whose parent/guardian provided) informed consent.* (6)

17 Youth (P4 Youth group, Placentia)

Standardized Questionnaire Used to Guide Focus Group Discussions

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Standardized Questionnaire Used to Guide Focus Group Discussions Community Questions: 1. What are some of the main strengths of your community/area? 2. What are some of the major challenges for your community/area?

Health Questions: 3. What makes a community healthy? 4. What are the main health concerns in your community? (Probe for groups that have particular needs.) 5. How do you think these concerns can be reduced or eliminated?

Health/Community Services Questions: 6. What issues or barriers do people in this area experience in accessing health/community services? 7. What opportunities do you see to improving health/community services in your community? 8. How can community resources be better utilized to improve the health and well-being of people in the area? Summary: 9. Thinking of all the concerns that have been discussed today that relate to health and well-being, what one issue is the most important to address?

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Standardized Questionnaire Used to Guide Youth Focus Group Discussion

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Standardized Questionnaire Used to Guide Youth Focus Group Discussion Eastern Health is talking to people in the Southern Avalon Region about health, and things related to health, in order to get an idea of the needs of the area. One group we want to talk to is young people. We want to hear your ideas and opinions about your community and your health. 1. What do you think is the best thing about living in your community? 2. What do you think is the most difficult thing about living in your community? 3. What things in your life help you to be healthy? 4. What things in your life make it difficult to be healthy? 5. What suggestions do you have for Eastern Health in terms of the services we offer in your community?

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Southern Avalon Community Health Needs Assessment Telephone Survey Report

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Southern Avalon Community Health Needs Assessment Telephone Survey Report

By Department of Corporate Strategy and Research (Eastern Health) The Telelink Call Centre (St. Johnâ&#x20AC;&#x2122;s)

February 28, 2007

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Project Team: Roger Chafe is a Planning Specialist with Eastern Health’s Department of Corporate Strategy and Research. Jane Macdonald is a Planning Specialist with Eastern Health’s Department of Corporate Strategy and Research. Vernon Smith is the head of Survey Research at the Telelink Call Centre.

Acknowledgements: The Southern Avalon Steering and Advisory Committees. Wayne Miller, Senior Director, Department of Corporate Strategy and Research, Eastern Health. Dr. Veeresh Gadag and Ann Ryan of Memorial University’s Health Research Unit. The staff of the Telelink Call Centre. Barbara Young, Research Analyst, Eastern Health. And especially, all of the residents of the Southern Avalon who participated in this telephone survey.

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Table of Contents Introduction................................................................................................................................. 119 Methodology ............................................................................................................................... 120 Survey Instrument................................................................................................................... 120 Training................................................................................................................................... 120 Sampling Methodology and Statistical Significance .............................................................. 120 Surveying Process................................................................................................................... 121 Data Analysis .......................................................................................................................... 122 Demographic Information of Respondents................................................................................. 123 Health Services ........................................................................................................................... 129 Satisfaction with Health Services ............................................................................................... 152 Community Health Challenges ................................................................................................... 169 Personal Health and Wellness..................................................................................................... 173

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Introduction Eastern Health is the largest health services organization in the province of Newfoundland and Labrador and has both regional and provincial responsibilities. The Eastern Health geographic region extends west from St. John’s to Port Blandford and includes all communities on the Avalon, Burin and Bonavista Peninsulas. Given the large geographic area served by Eastern Health, the Board of Trustees identified the need to conduct community health needs assessments for specific areas to understand their health-related needs. In June 2006, the first of these community health needs assessments was completed for communities on the Burin Peninsula. The Southern Avalon was identified as the second region for which to conduct a needs assessment. This area includes all of the communities along the Southern Avalon from Bay Bulls to Long Harbour-Mount Arlington Heights (comprising Economic Zone 18 – Avalon Gateway and Economic Zone 20 – the Irish Loop). This telephone survey was conducted as part of the larger Southern Avalon Community Health Needs Assessment. Its aim was to hear from residents about their use of health and community services, their level of satisfaction with these services, their self-reported health status, and what they saw as the main health challenges faced by their communities. The survey also identifies any barriers residents felt they faced in getting the services they needed or in maintaining and improving their health. The Southern Avalon Community Health Needs Assessment has an Advisory Committee, consisting of community representatives from the Southern Avalon Region, and a Steering Committee, consisting of Eastern Health staff who work across the Southern Avalon. Both of these committees offered guidance on the telephone survey. The Telelink Call Center (St. John’s, Newfoundland and Labrador) was contracted by Eastern Health to conduct the telephone survey. Some of the key findings of this survey include: | Many of the community health issues facing the Southern Avalon are similar to those faced by other parts of rural Newfoundland and Labrador, and in particular, those issues identified in the Burin community needs assessment. | There is a fairly high level of satisfaction with the health services available in the area. | Access issues need to be addressed for some services in terms of improving availability, wait times, and transportation issues. | Concern was expressed about the availability of some services, e.g., dental services, addiction and mental health services, and family doctors. | In some cases, Eastern Health needs to do a better job informing communities about the services that are available in the region and how residents can access these services.

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Methodology Survey Instrument The questionnaire used in this telephone survey is based upon questionnaires developed by Ann Ryan, Dr. Veeresh Gadag and others from Memorial University’s Health Research Unit (HRU). Specifically, the survey builds upon other HRU instruments used in needs assessment for the Grenfell Regional Health Services Survey (1999), Bell Island (2005), downtown St. John's (2005) and the Burin Peninsula (2006). The survey instrument has been modified for the Southern Avalon Telephone Survey by the project team. The project’s Steering Committee, Advisory Committee and Barbara Young, a research analyst with Eastern Health, reviewed the questionnaire before it was finalized. In training with Telelink staff, further revisions were identified and made to the survey instrument. The final draft of the questionnaire was programmed into Telelink’s Computer Assisted Telephone Interviewing (CATI) system. The questionnaire was piloted with 10 residents on the Southern Avalon before the full survey was conducted and no changes were deemed necessary. Training Telelink’s agents conducted the telephone survey. Training for the project included a group session, led by the project team, for all agents assigned to the project. During this session, the questionnaire was reviewed and all possible responses to individual questions were entered into the software so that agents could better anticipate how respondents might react to certain questions and scenarios. In addition to this training session, prior to conducting the survey, agents engaged in on-the-phone role playing to become more thoroughly familiar with the survey instrument.

Sampling Methodology and Statistical Significance In order to ensure that variations in need across the Southern Avalon were not missed, the area was divided into three regions so as to allow for sub-regional analysis. The regions were divided based on population base (i.e., similar sized areas) and by determining which sub-regions were logical given the geography of the Southern Avalon. The Steering and Advisory Committees made recommendations regarding the subdivision of the regions. The communities assigned to each region are identified below, along with the total population for each region according to the 2001 census.

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Region A: Bay Bulls - Renews-Cappahayden – Population 5,805 (2001 census) Bay Bulls, Witless Bay, Mobile, Tors Cove, Burnt Cove, Bauline East, La Manche, Brigus South, Admiral's Cove, Cape Broyle, Calvert, Ferryland, Aquaforte, Fermeuse, Port Kirwan, Kingman's, and Renews-Cappahayden.

Region B: Portugal Cove South - North Harbour – Population 4,811 (2001 census) Portugal Cove South, Biscay Bay, Trepassey, St. Shott's, St. Vincent's-St. Stephens-Peter's River, Gaskiers-Point La Haye, Path End, St. Mary's, Riverhead, Gulch, Mal Bay, Admiral's Beach, O'Donnells, St. Joseph's, New Bridge, Forest Field, Mount Carmel-Mitchell's Brook-St. Catherine's, Harricott, Colinet and North Harbour.

Region C: Branch to Long Harbour-Mt. Arlington Heights – Population 6,699(2001 census) Branch, Point Lance, St. Bride's, Cuslett, Angels Cove, Patrick's Cove, Gooseberry Cove, Ship Cove, Great Barasway, Little Barasway, Point Verde, Placentia, Argentia, Fox Harbour, Ship Harbour and Long Harbour-Mount Arlington Heights. The telephone survey aims to capture the views of residents on the Southern Avalon who are 19 years of age and older. Based on the latest census, the total population in the area 19 years of age and older was 13,265. In order to maintain a 95% confidence level within a confidence interval of + or - 5%, it was calculated that a survey size of 373 was required. In other words, with a sample size of 373, we could be assured that the responses given in the survey for the region as a whole are correct within + or - 5%, 19 times out of 20. Based on discussions with the project team, it was decided to aim to collect an equal number of surveys from each subregion. The data would then be weighted so that no region was disproportionally represented in the total sample.

Surveying Process Interviews were conducted between November 28 and December 9, 2006. As noted above, interviews were conducted using a Computer Assisted Telephone Interviewing (CATI) system and the automatic dialer. All listed residential telephone numbers for the sampling area were obtained from an electronic database and were randomized prior to being loaded into the automatic dialer. The dialer placed calls and those that were live-answered were passed to an available agent. The agent introduced him or herself and invited the respondent to take part in the survey as follows: “Hello, my name is ________________. I am calling on behalf of Eastern Health. Eastern Health is the regional health board responsible for providing health and community services in your area. I am calling about a health survey for residents of the Southern Avalon. I would really appreciate some of your time this morning/ afternoon/ evening.”

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If the person agreed, and was determined to be at least 19 years of age, the agent read the “Statement of Verbal Consent” and proceeded with the interview. During the course of the survey, a total of 6857 calls were made. Of that number, 365 resulted in “Completed” interviews, 33 interviews were “Partial Completes”, 756 were classed as “Potential Leads”, 498 resulted in “Refusals”, 2471 calls went to an “Answering Machine”, 2326 were “No Answer”, 341 were “Busy”, and 67 were “No Longer in Service”. The 365 completed interviews represent approximately 22 % of the 1652 calls where a person answered the phone. Although 365 respondents is less than the target sample of 373, the project team decided that the sample was sufficient. Given that every phone number in the area was called at least once, seeking additional respondents would require calling back residents who may have initially refused to complete the survey. In the end, with a sample of 365, the results of the survey are correct within + or - 5.06%, 19 times out of 20.

Data Analysis The collected data was imported into an SPSS (Statistical Package for the Social Sciences) computer software program for analysis. Prior to analysis, the data was weighted by population, 19 years of age and older, in each region. Weighting ensures that neither sub-region is given disproportional significance within the total survey. Comparisons in the text are all based on weighted data.

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Demographic Information of Respondents

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The survey was completed by 365 residents of the Southern Avalon. As reported in Table A, these respondents represent 840 household members, or 4.85% of the regionâ&#x20AC;&#x2122;s total population. Table A: Household Members and Age Distribution by Regions REGION A REGION B REGION C Under 19 years 60 37 32 (19%) (16%) (11%) 19 years and older 256 189 266 (81%) (84%) (89%) Total 316 226 298

TOTAL 129 (15%) 711 (85%) 840

Comparing the Southern Avalon sample to provincial and national data, we can see that the sample population has a noticeably lower percentage of dependents than the provincial or national average. For example, the sample in Region C has less than half the rate of household members under 19 than the provincial or national average. The sample also has a lower level of dependents than the sample reported in the Burin Health and Community Needs Assessment Telephone Survey Results. Table B: Household Members and Age Distribution by Region, Burin, Newfoundland and Labrador, and Canada Southern Burin Newfoundland Canada1 1 1 Avalon Region and Labrador Under 19 years 129 262 128* 785* (15.4%) (21.1%) (25.0%) (24.6%) 19 years and older 711 977 384* 2407* (84.6%) (78.9%) (75.0%) (75.4%) Total 840 1239 512* 3192* * NL and Canada number X 103

The Burin Health and Community Needs Assessment Telephone Survey Results, p. 8. Accessed February 12, 2007 at http://www.easternhealth.ca/BurinNeedsAssessment.pdf .

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Table C presents the gender of respondents. The gender division for the province is 51.07% Female and 48.93% Male.2 With 75.34% of respondents being female, the sample is clearly biased towards female respondents. Telelink reports that a female bias is fairly standard for telephone surveys. Almost the same breakdown in gender was reported in the Burin telephone survey (76.1% Female and 23.7% Male).3 Table C: Gender of Respondents Male 88 (24.11%) Female 275 (75.34%) Unidentified 2 (0.55%) Total 365 Table D reports the age distribution for respondents wherein 84.93% of respondents were over the age of 40. According to Statistics Canada, only 52% of the Canadian adult population is over the age of 45.4 It appears then that the sample may be somewhat older than the general Canadian population. Table D: Age distribution of respondents 19 to 29 years 17 (4.66%) 30 to 39 years 38 (10.41%) 40 to 49 years 76 (20.82%) 50 to 59 years 117 (32.05%) 60 to 69 years 62 (16.99%) Above 70 years 55 (15.07%) Total 365 2

Calculated from Newfoundland and Labrador Community Accounts â&#x20AC;&#x201C; Newfoundland and Labrador Demographic Accounts. Accessed February 12, 2007 at http://www.communityaccounts.ca/CommunityAccounts/OnlineData/table_d7r.asp?comval=prov&whichacct=demo graphic.

The Burin Health and Community Needs Assessment Telephone Survey Results, p. 8. Accessed February 12, 2007 at http://www.easternhealth.ca/BurinNeedsAssessment.pdf. 4

Calculated from Statistics Canada - Community Profiles. Accessed February 12, 2007 at http://www12.statcan.ca/english/profil01/CP01/Details/Page.cfm?Lang=E&Geo1=PR&Code1=10&Geo2=PR&Cod e2=01&Data=Count&SearchText=Newfoundland%20and%20Labrador&SearchType=Begins&SearchPR=01&B1= All&GeoLevel=&GeoCode=10.

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Table E presents the annual before-tax household incomes by region. In 2004, the median family income in Newfoundland and Labrador was $35,700.5 Taking the mid-point of the $30,000 to < $40,000 bracket as the medium point, 53.97% of the sample population has incomes above the provincial median. Table E: Yearly Household Income - by region REGION A REGION B Less than $10,000 1 8 (0.82%) (7.77%) $10,000 to < $ 20,000 22 18 (18.03%) (17.48%) $20,000 to < $30,000 20 17 (16.39%) (16.50%) $30,000 to < $40,000 22 15 (18.03%) (14.56%) $40,000 to < $50,000 12 11 (9.84%) (10.68%) $50,000 to < $60,000 2 6 (1.64%) (5.83%) $60,000 to < $70,000 5 4 (4.10%) (3.88%) $70,000 to < $80,000 2 2 (1.64%) (1.94%) $80,000 + 14 6 (11.48%) (5.83%) Donâ&#x20AC;&#x2122;t Know 7 6 (5.74%) (5.83%) Refused 15 10 (12.30%) (9.71%) Total 122 103

REGION C 7 (5.00%) 24 (17.14%) 24 (17.14%) 17 (12.14%) 9 (6.43%) 8 (5.71%) 7 (5.00%) 2 (1.43%) 14 (10.00%) 15 (10.71%) 13 (9.29%) 140

TOTAL 16 (4.38%) 64 (17.53%) 61 (16.71%) 54 (14.79%) 32 (8.77%) 16 (4.38%) 16 (4.38%) 6 (1.64%) 34 (9.32%) 28 (7.67%) 38 (10.41%) 365

Province of Newfoundland. Community Accounts. Accessed February 12, 2007 at http://www.communityaccounts.ca/communityaccounts/onlinedata/table_i1.asp?comval=prov&whichacct=income.

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Statistics Canada calculates low income cut-offs (LICOs). This threshold reflects the point at which families are likely to spend 20% more of their income on necessities, such as food and shelter, than the average Canadian family. Being below the LICOs is seen as an indication that a family may face economic difficulties. Because family size and location affect the cost of living, the LICOs are determined by these factors. Table F gives the LICOs for rural communities (i.e., communities with less than 15,000 residents) by family size.6 Table F: Low income cut-offs (1992 base) after tax 1 person $14,303 2 persons $17,807 3 persons $21,891 4 persons $26,579 5 persons $30,145 6 persons $33,999 7 or more persons $37,853 Using the income and the household size questions on the survey, we can roughly calculate the number of families who are below the LICO in the region. Since the categories captured by the income question do not match up with the Statistics Canada categories, we have taken the midpoint of the income range as a proxy income level. The income points are outlined in Table G. Table G: Mean Household Income Less than $10,000 $10,000 to < $ 20,000 $20,000 to < $30,000 $30,000 to < $40,000 $40,000 to < $50,000 $50,000 to < $60,000 $60,000 to < $70,000 $70,000 to < $80,000 $80,000 +

< $10,000 $15,000 $25,000 $35,000 $45,000 $55,000 $65,000 $75,000 > $80,000

Statistics Canada â&#x20AC;&#x201C; Income Research Paper Series: Low Income Cut-offs for 2005 and Low Income. Accessed February 12, 2007 at http://www.statcan.ca/english/research/75F0002MIE/75F0002MIE2006004.pdf.

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The number of households which fall below the LICO in each region is presented in Table H. For the region as a whole, approximately 17.2% of households fall below the LICO. At 22%, Region B has the highest rate of households below the LICO. Provincially, 16.3% of households are below the LICO.7 The national average shows that 15.5% of households fall below the LICO.8 The Burin Health and Community Needs Assessment Telephone Survey Results found that 24% of households surveyed were below the LICO.7 TABLE H: LICO by Region BELOW LICO REGION A 16 (15.7%) REGION B 19 (22.0%) REGION C 17 (15.0%) TOTAL 52 (17.2%)

ABOVE LICO 86 (84.3%) 67 (78.0%) 96 (85.0%) 249 (82.8%)

TOTAL 102 86 113 301

The Burin Health and Community Needs Assessment Telephone Survey Results, p. 34. Accessed February 12, 2007 at http://www.easternhealth.ca/BurinNeedsAssessment.pdf. 8

Statistics Canada - Persons in low income before tax, by prevalence in per cent (2000 to 2004). Accessed February 12, 2007 at http://www40.statcan.ca/l01/cst01/famil41a.htm.

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Section 1: Health Services

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Health Services - Family Doctors: Family doctors play a key role in the delivery of health care. Access to a family doctor is also important for accessing other required health and community services. Our survey found that 320 of the 365 respondents (88%) report having a regular family doctor. These results are in line with the numbers we found in Burin (88.7%). Table 1: Do you have a regular family doctor? Frequency Per cent Yes No Total

320 45 365

88 12 100

There were some regional variations in peopleâ&#x20AC;&#x2122;s access to family physicians. Thirty-four of the 45 respondents (76%) who reported not having a family doctor are located in Region C.

Table 1a: Do you have a regular family doctor?

Yes No Total

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REGION A Frequency Per cent 117 96 5 4 122 100

REGION B Frequency Per cent 97 94 6 6 103 100

REGION C Frequency Per cent 106 76 34 24 140 100

Location of Family Doctor:

When asked where their community doctor was located, the overall most common responses (as seen in Table 2) were Placentia (25%), Trepassey (20%), Bay Bulls (14%), and St. John’s (13%). Table 2: In which community is your family doctor located?

Bay Bulls Carbonear Ferryland Placentia St. Mary's St. John's Trepassey Kelligrews Kilbride CBS Goulds Holyrood Mount Pearl Paradise Whitbourne Total

Frequency

Per cent

44 2 24 82 10 41 64 3 2 3 14 18 7 2 5 320

14 >1 8 25 3 13 20 1 >1 >1 5 6 2 >1 1 100

Table 2a: In which community is your family doctor located? (by Region) REGION A REGION B REGION C Bay Bulls Trepassey Placentia (37.7%) (51.7%) (75.6%) Ferryland Holyrood St. John's (21.1%) (18.1%) (12.2%) St. John's St. John's Whitbourne (14.9%) (11.2%) (4.4%) Trepassey St. Mary's Mount Pearl (12.3%) (10.3%) (3.3%) Goulds Kelligrews Carbonear (11.4%) (3.4%) (2.2%) Mount Pearl CBS Kilbride (1.8%) (2.6%) (1.1%) Kilbride Mount Pearl Paradise (0.9%) (1.7%) (1.1%) Paradise (0.9%)

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Of the 117 respondents in Region A who reported having a family doctor, Bay Bulls (38%), Ferryland (21%), and St. John’s (15%) were the most commonly reported towns in which their doctors were located.

Of the 97 respondents in Region B who reported having a family doctor, Trepassey (51%), and Holyrood (18%) were the two most commonly reported towns in which their doctors were located.

Of the106 respondents in Region C who reported having a family doctor, Placentia (76%), and St. John’s (12%) were the two most commonly reported towns in which their doctors were located.

Travel Time to Family Doctor’s Office:

Of the 320 respondents who have a family doctor, 128 of them (40%) reported having to travel up to 10 minutes from their home to their doctor’s office (see Table 3). Table 3: What is the average travel time from your home to your doctor's office?

Up to 10 minutes 11 to 20 minutes 21 to 30 minutes 31 minutes to 1 hour 1 to 1.5 hours Total

Frequency

Per cent

128 47 37 70 38 320

40 15 11 22 12 100

Table 3a: What is the average travel time from your home to your doctor's office? REGION A REGION B REGION C Frequency Per cent Frequency Per cent Frequency Per cent Up to 10 42 36 28 29 58 54 minutes 11 to 20 18 15 14 14 15 14 minutes 21 to 30 15 13 16 17 6 6 minutes 31 32 27 28 29 10 10 minutes to 1 hour 1 to 1.5 10 9 11 11 17 16 hours Total 117 100 97 100 106 100

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There was a significant difference (p = 0.00) in travel times among the three regions.

In both Region A and Region B, respondents most commonly had to travel up to 10 minutes (36% and 29% respectively), or between 31 minutes and an hour (27% and 29%) to get to their doctor’s office.

In Region C, the majority of respondents reported a travel time to their doctor’s office of up to 10 minutes (54%), while the second most common response was from one hour to one hour and a half (16%).

Satisfaction with Travel Time:

Figure 1: How satisfied are you with the travel time to your doctor's office? Very Dissatisfied (6%) Moderately Dissatisfied (6%)

Neither Dissatisfied nor Satisfied

(16%) Moderately Satisfied (13%) Very Satisfied (59%) No Opinion (> 1%)

Length of Time Respondent has been with the Same Doctor:

A total of 239 of the 320 respondents (75%) have been with the same doctor for five years or more (see Table 4). Table 4: How long have you been going to the same family doctor?

Less than 1 year 1 year to less than 2 years 2 years to less than 5 years 5 years or more Total

Frequency

Per cent

28 13 40 239 320

9 4 12 75 100

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Table 4a: How long have you been going to the same family doctor? REGION A REGION B REGION C Frequency Per cent Frequency Per cent Frequency Per cent Less than 1 year 13 11 8 8 7 7 1 year to less than 2 3 3 2 2 8 8 years 2 years to less than 5 years 5 years or more Total

117

100

106

100

There was no significant variation (p = 0.145) in the length of time respondents have been seeing the same doctor, among the 3 regions. In other words, region or location of the respondent appears to have no affect on the respondent’s propensity to stay with a family doctor.

Wait Times to Get an Appointment with a Family Doctor:

When asked how long they had to wait to see a family doctor, approximately 78 per cent of respondents were able to see their doctor by the next day, and a further 18 per cent were able to see their doctor within a week (see Table 5).

No respondents, in any region, reported having to wait between two and three weeks to see their family doctor.

Table 5: How long do you usually wait to get an appointment with your family doctor?

Same day Next day Within a week 1 to 2 weeks More than 3 weeks Total

134

Frequency

Per cent

100 58 8 2 320

47 31 18 3 1 100

Table 5a: How long do you usually wait to get an appointment with your family doctor? REGION A REGION B REGION C Frequency Per cent Frequency Per cent Frequency Per cent Same day 54 46 49 51 48 46 Next day 42 36 29 30 29 27 Within a week 18 15 12 12 29 27 1 to 2 weeks 3 3 5 5 0 0 More than 3 0 0 2 2 0 0 weeks Total 117 100 97 100 106 100

The difference in wait times to see their doctor was not significantly different among regions (p = 0.016). In all regions, the majority of respondents (78%) reported being able to see their family doctor at the worst, by the day following the request for an appointment. Only in Regions A and B were there reports of respondents having to wait one to two weeks; the frequency of this response for these regions was three percent and five per cent respectively. In Region B, two out of 97 respondents (2%) reported having to wait more than three weeks.

Satisfaction with Wait Time to See the Family Doctor:

Figure 2: Satisfaction with wait time to get an appointment with a family doctor

Very dissatisfied (3%) Moderately dissatisfied (3%) Neither dissatisfied nor satisfied (8%) Moderately satisfied (16%) Very satisfied (70%)

` Further analysis revealed that none of the respondents in Region C were very dissatisfied with the wait time to get in to see their doctor, even though 27 per cent of these individuals reported having to wait up to a week to get an appointment.

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Availability of Alternate Family Doctors When asked if they could see another family doctor, if their own was not available, 192 respondents (60%) of the 320 who have regular family doctors said that they could. Table 6: Are you able to see another family doctor if yours is not available?

Yes No Sometimes Don't know Total

Frequency

Per cent

192 90 12 26 320

60 28 4 8 100

Table 6a: Are you able to see another family doctor if yours is not available? REGION A REGION B REGION C Frequency Per cent Frequency Per cent Frequency Per cent Yes 85 73 35 36 73 69 No 16 14 52 54 22 21 Sometimes 4 3 4 4 3 3 Don't know 12 10 6 6 8 7 Total 117 100 97 110 106 100

There was a significant difference (p = 0.00) between availability of alternate doctors among the three regions. Further analysis showed that 73 per cent of respondents in Region A, and 69 per cent of respondents in Region C stated they could see an alternate doctor. Only in Region B did the majority state that they could not see an alternate doctor should theirs not be available. Here, 52 of the 97 respondents (54%) made this report.

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Reasons Why Respondent has no Family Doctor Of the 45 respondents who did not have a family doctor, the most common reasons cited were that the respondent had not looked for a regular family doctor (20%) or that the previous family doctor had left the area (16%). (See Table 7) Approximately 11 per cent reported no specific reason for not having a family doctor. Table 7: Why do you not have a family doctor? Frequency

Per cent

5 9 7 4 5 3 4 4 3 1 45

11 20 16 8 11 7 9 9 7 2 100

No doctor in the area - too far to travel Have not looked for a regular family doctor Previous family doctor left the area No doctors in the area No reason identified Never sick - not often sick Not satisfied with doctor Doctors change too often Go to a clinic or a hospital Go to a nurse practitioner Total

There was no significant relationship (p = 0.027) between region and the reason for not having a family doctor.

Medical Care for Respondents with no Family Doctor When asked what they would do for medical care in the absence of a family doctor, most respondents reported that they would go to any family doctor available (36%), or go to the emergency department of a hospital (37%). (See Table 8) Table 8: What do you do for medical care, in the absence of a family doctor?

Go to any family doctor available Go to the Emergency Department of a hospital Go to a clinic Go without care Visit a nurse practitioner Haven't been sick Total

Frequency

Per cent

16 17 8 1 2 1 45

36 37 17 2 5 2 100

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The difference between regions, while interesting with respect to the use of alternate health care professionals, was not significant (p = 0.03). Of the five respondents in Region A, three reported that they would go to a clinic (60%), while two would go to any family doctor available (40%). Of the seven respondents in Region B, two reported that they would go to any family doctor available (29%), two reported that they would go to the emergency department of a hospital (29%) and three reported that they would visit a nurse practitioner (42%). Region C had the highest incidence of respondents not having a family doctor. Of the 33 respondents, 14 were most likely go to the Emergency Department of a hospital (43%), 12 reported they would go to any family doctor available (37%), and five reported they would go to a clinic (14%). One person reported that they would go without care in such situations; and one person said that they haven’t been sick.

Urgent Appointments and Family Doctor Availability When asked if they could see a family doctor on the same day, should they need an urgent appointment, 262 respondents (72%) said they could see one. (See Table 9) Approximately eight per cent of respondents (31 of 365) said they did not know whether or not they could see a doctor for an urgent appointment that same day. On an anecdotal level, many respondents reported not having had the need to avail of this particular service, or alternatively, they would travel to a hospital center should it be an emergency. Table 9: If you need an urgent appointment, can you normally see a family doctor that same day? Frequency Per cent Yes No Sometimes Don't know Total

138

262 53 19 31 365

72 15 5 8 100

Table 9a: If you need an urgent appointment, can you normally see a family doctor that same day? REGION A REGION B REGION C Frequency Per cent Frequency Per cent Frequency Per cent Yes 104 85 76 74 83 59 No 8 7 16 15 29 21 Sometimes 3 2 6 6 10 7 Don't know 7 6 5 5 18 13 Total 122 100 103 100 140 100

There was a significant difference (p = 0.00) between respondents’ answers among the three regions. There was a much greater proportion of respondents that reported not being able to see another family doctor that same day, in Region C, than in the other two regions. A total of 104 respondents (85%) in Region A could see a doctor the same day, and eight (7%) said they could not, in urgent situations. In Region B, 76 respondents (74%) could see a doctor that same day, while 16 (15%) said they could not.

In Region C, the majority of respondents, 83 of 140 (59%) reported they could see a family doctor the same day while 29 respondents (21%) reported that they could not.

Medical Care in Urgent Situations – If no Doctor is Available: A total of 53 respondents said they were not able to see any family doctor when in need of an urgent appointment. In such cases, respondents reported most frequently that they would go to the emergency department of a hospital (72%). A total of 14 per cent said they would go to a clinic, and 14 per cent said they would go without care.

Figure 3: What do you do for medical care in these situations? Go to the emergency department of a hospital (72%) Go to a clinic (14%)

Go without care (14%)

139

There was no significant difference between regions (p = 0.533) in how respondents replied to this question. Of the 53 respondents that were not able to see any family doctor, seven of them, or 13 per cent, reported they would go without care. In Region A, just one of the eight respondents (13%) who said they could not see a doctor when in need of urgent care would go without care. In Region B, of the 16 respondents who said they could not see a doctor when in need of urgent care, four of them (25%) reported they would not seek medical care. In Region C, just two of the 29 respondents (7%) who said they could not see a doctor when in need of urgent care would go without care. Clinic use in urgent situations also varied among Regions, though again not significantly. One in eight respondents (13%) said they would go to a clinic, in both Region A and Region B; in Region C, five of the 29 respondents (17%) said they would go to a clinic in these circumstances.

Community Health Nurses “Community health nurses work in the community and offer services like immunizations, newborn visits and dressing changes.” (Survey instrument, introduction to question 8a.) A total of 134 of the 365 respondents (37%) reported visiting a community health nurse during the past 12 months. (See Table 10) Table 10: Has anyone in your household seen a community health nurse in the last year?

Yes No Total

Frequency

Per cent

134 231 365

37 63 100

Table 10a: Has anyone in your household seen a community health nurse in the last year? REGION A REGION B REGION C Frequency Per cent Frequency Per cent Frequency Percent Yes 53 43 49 48 32 37 No 69 57 54 52 108 63 Total 122 100 103 100 140 1010

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There was a significant difference (p = 0.00) between reported community health nurse visits among regions. A total of 53 respondents (43%) in Region A, and 49 respondents (48%) in Region B reported having seen a community health nurse in the past 12 months. Respondents in Region C reported the lowest frequency of community health nurse visits, where only 32 respondents (37%) reported to have visited one.

Frequency of Visits to the Community Health Nurse: Of the 133 respondents who visited a community health nurse during the last year, three (2%) reported not knowing how many visits they had made. Figure 4: How many times have you or someone in your household visited a community health nurse in the past year?

1 time (23%) 2 times (22%) 3 times (10%) 4 times (9%) 5 or more times (34%) Don't Know (2%)

There were no discernable trends among regions, and there was no significant difference (p = 0.414) in community health nurse visits, among the three regions.

Nurse Practitioners: “Nurse practitioners offer more specialized services than other community nurses. For example, a nurse practitioner can write some prescriptions and order certain diagnostic tests. They usually work within a hospital setting or clinic.” (Survey instrument, introduction to question 9a.)

141

A total of 70 respondents (19%) reported having visited a nurse practitioner in the past 12 months (see Table 11). Table 11: Has anyone in your household seen a nurse practitioner in the last year? Frequency 70 295 365

Yes No Total

Per cent 19 81 100

Table 11a: Has anyone in your household seen a nurse practitioner in the last year? REGION A REGION B REGION C Frequency Per cent Frequency Per cent Frequency Per cent Yes 5 4 36 35 29 21 No 117 96 67 65 111 79 Total 122 100 103 100 140 100

A significant relationship exists between regions and nurse practitioner visits (p = 0.00). Further analysis revealed that respondents in Region A had the lowest frequency of visits to nurse practitioners. Only five of them (4%) reported having made any such visits during the past 12 months. Region B reported the highest incidence of respondents visiting nurse practitioners with 36 of them (35%) having made such a visit in the past 12 months. Twenty nine respondents (21%) in Region C reported visiting a nurse practitioner in the past 12 months.

Frequency of Visits to the Nurse Practitioner: Figure 5: How many times have you or someone in your household visited a nurse practitioner in the past year?

1 time (38%) 2 times (21%) 3 times (10%) 4 times (14%) 5 or more times (13%) Don't Know (3%)

142

There were no discernable trends among regions, and there was no significant difference (p = 0.474) between nurse practitioner visits among the three regions.

Dental Services A total of 167 respondents reported having visited a dentist in the last 12 months (see Table 12). Table 12: Have you seen a dentist in the last twelve months? REGION A REGION B Frequency Per cent Frequency Per cent Yes 59 48 40 39 No 63 52 63 61 Total 122 100 103 100

REGION C Frequency Per cent 68 49 72 51 140 100

In Region A, 59 respondents (48%) reported visiting a dentist in the last year, and in Region C, 68 respondents (49%) reported using dental services. Only 40 respondents (39%) in Region B reported a dentist visit. A total of 127 respondents have dental insurance (35%). A total of 44 respondents in Region A (36%), 35 in Region B (34%) and 48 in Region C (34%) reported having dental insurance. Fifteen uninsured respondents (13%) sought dental services in Region A. Five uninsured respondents (5%) sought dental services in Region B and 20 uninsured respondents (14%) sought dental services in Region C.

143

Dentists and Urgent Appointments: When asked if they could see their dentist if they needed an urgent appointment, 29% said they could, while 27% said they had not had the occasion, or that it was not applicable.

Figure 6: Can you see your dentist the same day if you need an urgent appointment?

Yes (29%) No (44%) Not applicable / Have not had occasion (27%)

A total of 57 respondents in Region C reported being able to see a dentist if they needed an urgent appointment (41%). In Region A, a total of 26 respondents said they could see a dentist that same day if they required an urgent appointment (21%). A total of 22 respondents in Region B (21%) said they could see a dentist should they require an urgent appointment.

Pharmacy Services When asked if they had a prescription filled in the last twelve months, 324 respondents (89%) said they did (see Table 13). Table 13: Have you had a prescription filled in the past year?

Yes No Total

144

Frequency

Per cent

324 41 365

89 11 100

Table 13a: Have you had a prescription filled in the past year? REGION A REGION B REGION C Frequency Per cent Frequency Per cent Frequency Per cent Yes 109 89 92 89 123 88 No 13 11 11 11 17 12 Total 122 100 103 100 140 100

There was no significant difference among the three regions (p = 0.900) in respondents having their prescriptions filled. Region A and B had the same percentage of respondents (89%) having prescriptions filled, where 109 respondents in Region A, and 92 respondents in Region B reported filling prescriptions. In Region C, 123 respondents (88%) had prescriptions filled.

Problems with Prescriptions: Only four respondents (2%) of the 324 who had prescriptions filled in the last year reported having problems. One report was in Region B and three respondents in Region C reported problems in getting their prescriptions filled. Two respondents in Region C reported that the pharmacy was not open at convenient hours. The respondent in Region B, as well as one in Region C stated that it was too far to travel to the pharmacy.

Only one respondent of the four who had problems made any further comments, and this respondent was located in Region C. They reported that their medication was not available in their area, and they had to travel into St. John’s to get their prescription filled.

145

Travel Time to the Nearest Pharmacy:

Over 80 per cent of all respondents reported a travel time of under 20 minutes to their nearest pharmacy.

Table 14: How long does it take to travel to the nearest pharmacy?

Up to 10 minutes 11 to 20 minutes 21 to 30 minutes 31 minutes to 1 hour 1 to 1.5 hours Total

Frequency

Per cent

200 98 20 35 11 365

55 27 6 9 3 100.0

Table 14a: How long does it take to travel to the nearest pharmacy? REGION A REGION B REGION C Frequency Per cent Frequency Per cent Frequency Per cent Up to 10 69 57 46 45 86 62 minutes 11 to 20 41 34 22 21 35 25 minutes 21 to 30 5 4 8 8 7 5 minutes 31 minutes to 1 3 2 22 21 10 7 hour 1 to 1.5 hours 4 3 5 5 2 1 Total 122 100 103 100 140 100

There was a significant difference (p = 0.00) between travel times to the nearest pharmacy, among regions. Region B reported greater travel times than the other two regions. Respondents in Region B reported having to travel more than 30 minutes most frequently (26%), followed by Region C (8%). Only seven respondents (5%) in Region A reported having to travel more than 31 minutes to their nearest pharmacy.

Free Home Delivery of Prescriptions: Of the 324 respondents who had filled prescriptions, only 98 of them (30%) reported having access to free home delivery, while a further 139 of them (43%) said this service was not available at their pharmacy. A total of 87 respondents (27%) stated that they did not know if their pharmacy offered free home delivery of prescriptions.

146

Region C had the fewest respondents (5%) who reported having access to free home delivery, while Region B had the highest incidence of availability of this service (53 per cent of respondents). In Region A, 39 per cent of respondents reported having access to free home delivery. A total of 34 respondents of the 98 who had access to this service, avail of it for most of their prescriptions. In Region C, only one of six respondents (17%) who reported having free home delivery available indicated that they use this service for most of their prescriptions. In Region A, only six of 43 (14%) who reported having free home delivery available indicated they use this service. In Region B, 26 of the 49 respondents (54%) who had access to this service reported using free home delivery service for most of their prescriptions.

Emergency Services Overall, when asked which hospital they would go to for emergency services, 240 of 365 respondents (66%) said they would go to hospitals in the St. John’s Area. All respondents in Region A reported they would go to hospitals in the St. John’s area, should they require emergency services. With one exception, all respondents in Region B said they would seek emergency services in St. John’s; the location mentioned by this respondent was Whitbourne. A total of 81 per cent of respondents in Region C were most likely to seek emergency services at the hospital centre in Placentia. Other locations respondents reported to seek emergency services were Whitbourne (4%), Carbonear (3%), and 13 percent said they would go to St. John’s.

147

Visits to the Hospital Emergency Department Â&#x2122; Of the 365 respondents, 143 of them (39%) reported that a member of their household had visited the Emergency Department of a hospital during the last twelve months (see Figure 7).

Number of Respondents

Figure 7: The number of times respondents visited Emergency Departments in Hospitals 35 30 25 20 15 10 5 0

Region A Region B Region C

1 time

2 times

3 times

4 times

5 or more times

Number of Visits

Â&#x2122; Of the respondents who did visit the Emergency Department, the most frequent report of the number of visits made, in all regions, was one visit per household. Â&#x2122; Only respondents in Region B and C reported visiting the Emergency Department five or more times.

148

Use of Ambulance Services: A total of 59 respondents reported that a member of their household had availed of ambulance services in the past 12 months.

Number of Respondents

Figure 8: The number of times respondents used ambulance services in the last year

14 12 10 8 6 4 2 0

Region A Region B Region C

1 time

2 times

3 times

4 times

5 or more times

Number of Times Ambulance Services Were Used

Region B had the highest use of ambulance services, where 25 respondents (24%) had reported using this service. In Region A, 17 respondents (14%) reported using ambulance services, and in Region C, a total of 17 respondents (12%) reported using this service, in the past twelve months. All respondents in Region A, who reported using ambulance services (n = 17), availed of the service once or twice. When asked why respondents had to use ambulance services, 100 per cent of respondents indicated that ambulance services had been used by them for medical emergencies.

Home Care “Home Care is a service provided in the home, to help a person with daily living tasks.” (Survey instrument, introduction to question 16a.) Of the 365 respondents, only 14 of them (4%) indicated that they or a member of their household had availed of home care services in the past year. Of these, two respondents were located in Region A, five in Region B, and seven in Region C.

149

Only two of these 14 individuals experienced problems while arranging for home care, one in Region A and one in Region B. One respondent reported having difficulties in finding a care giver, and the second said there was so much red tape, it made setting up services difficult.

Long Term Care Facilities: Personal Care Homes: “A Personal Care Home is a facility that provides residential care for individuals who require assistance in the activities of daily living.” (Survey instrument, introduction to question 17a.) A total of 5 respondents, one located in Region B, and two from both Region A and Region C reported admitting a member of their household to a personal care home. There was no significant relationship (p = 0.909) in personal care home admittance among the three regions. No problems were reported by any respondents, with respect to admitting a household member to a personal care home.

Nursing Homes: “A Nursing Home is a facility that provides 24-hour skilled nursing care to people who are limited in their ability to function independently.” (Survey instrument, introduction to question 18a.) Of the 365 respondents, only three individuals reported admitting a member of their household to a nursing home. Two of the respondents were located in Region A, and one in Region C. None of the three respondents reported any problems with arranging care.

Impediments to Receiving Health Care, Community Services or Medical Advice When asked if anything prevented any member of their household from receiving health care, community services or medical advice, only 10 of the 365 (3%) respondents said there had been such instances.

150

Region A:

A total of three respondents in Region A reported being prevented from receiving health services.

One respondent said the wait for service was too long, and one cited weather conditions as the factor that kept them from receiving medical care. In the comments section, one respondent said that someone in their household was released from hospital before they were able to care for themselves, and subsequently had no access to assistance of any kind. Region B:

Three respondents in Region B indicated that they had been prevented from receiving health services.

One respondent cited travel distance and the wait time for service as the impediments that kept them from receiving care. One respondent said that the doctor’s schedule had changed abruptly, and subsequently they had no means to gain access to their blood pressure prescription. Another respondent said the lack of consistent medical service in their region precluded them from getting medical care. In the comments section, one respondent reported problems getting their blood work done, as they had not been given appropriate instructions on fasting. Their second attempt to have blood work done was equally non-productive, as no one was available at blood services; the respondent was told that they had come at the wrong time.

Region C:

A total of four respondents in Region C experienced difficulties.

Three respondents in this area were limited by transportation; two respondents could not afford transportation and one said they could not arrange transportation. One respondent also said that travel distance kept them from the services required. In the comments section, one respondent said that the doctor in the area was no longer taking new patients, and one respondent said that the doctor on call did not “come in”.

151

Section 2: Satisfaction with Health Services

152

Satisfaction with Health Services For the purpose of clarity, respondents who reported having no opinion, and those who did not use the service were omitted from visual aids in this section. These numbers are recorded in the text preceding all figures, with relative frequencies based on the entire sample (n=365). Frequencies in the legend are based on the number of respondents who expressed an opinion about the service.

Family Doctors: A total of 12 respondents (4%) reported not using this service and 3 respondents (1%) reported having no opinion.

Figure 9: Family Doctors

n = 350 Very dissatisfied (3%) Somewhat dissatisfied (3%) Neither satisfied nor dissatisfied (7%) Somewhat satisfied (20%) Very satisfied (67%)

The majority of respondents (67%) reported being very satisfied with family doctor services. A total of nine respondents (2%) reported being very dissatisfied with family doctor services. Five respondents reported that care was not available in their area and three respondents said that family doctors don’t stay in their areas long enough.

153

Emergency Service: A total of 97 respondents (27%) reported that they did not use emergency services, and 9 (2%) had no opinion.

Figure 10: Emergency Services

n = 259

Very dissatisfied (10%) Somewhat dissatisfied (11%) Neither satisfied nor dissatisfied (15%) Somewhat satisfied (23%) Very satisfied (41%)

Of the 26 respondents (10%) who reported to be very dissatisfied with emergency service, the most commonly reported issue was wait time, cited by 23 respondents. Six respondents also cited the availability of care in one’s area as an explanation for their dissatisfaction with this service.

Ambulance Services: A total of 171 respondents (47%) reported that they did not use the service, and 7 (2%) reported that they had no opinion.

Figure 11: Ambulance Services

n = 187

Very dissatisfied (2%) Somewhat dissatisfied (1%) Neither satisfied nor dissatisfied (9%) Somewhat satisfied (16%) Very satisfied (72%)

154

The majority of the 187 respondents (72%) who expressed an opinion on ambulance services, reported being very satisfied. Only three respondents reported being very dissatisfied with ambulance services, two reporting that wait times were too long. In the comments section, one respondent reported that having to pay for emergency transportation to a hospital was “just not good enough”.

Hospital In-Patient Services: Of the 365 respondents queried, 136 of them (37%) reported they didn’t use this service, and an additional 18 respondents (5%) had no opinion of hospital in-patient services.

Figure 12: Hospital in-patient Services

n =211

Very dissatisfied (3%) Somewhat dissatisfied (4%) Neither satisfied nor dissatisfied (11%) Somewhat satisfied (25%) Very satisfied (57%)

Of the 7 respondents (3%) who reported being very dissatisfied with hospital in-patient services, three cited wait times as being too long. One respondent said that care was not available in their region, and three respondents reported that care was poor or insufficient. Five respondents gave additional comments. One respondent disclosed that a household member had received a misdiagnosis and had not received the care necessary for the condition. One respondent reported being released from hospital too soon following surgery, and one that adequate care was not provided while in hospital. There was also one complaint regarding the meals provided by the hospital.

155

Hospital Out-Patient Services: Of the 365 respondents, 172 of them (47%) had no opinion, and 15 (4%) had not used the service.

Figure 13: Hospital out-patient Services

n = 178

Very dissatisfied (9%) Somewhat dissatisfied (7%) Neither satisfied nor dissatisfied (17%) Somewhat satisfied (23%) Very satisfied (44%)

Of the 178 respondents who did express an opinion, over half of them (67%) expressed satisfaction with out-patient services. A total of 18 individuals (9%) reported being very dissatisfied with out-patient services. The most common complaint among this group was that wait times were too long. One respondent reported that care was not available in their area, and another two stated they felt the service in out-patients was poor. In the comments section, respondents reported having trouble arranging for care (i.e. mammograms and chemotherapy). Travel time was also reported as a reason for dissatisfaction with this service.

156

Dental Services: A total of 119 respondents (33%) did not use this service, and 12 (3%) reported no opinion.

Figure 14: Dental Services

n = 234

Very dissatisfied (11%) Somewhat dissatisfied (3%) Neither satisfied nor dissatisfied (16%) Somewhat satisfied (24%) Very satisfied (46%)

Most respondents (70%) were either very or somewhat satisfied with dental services. Twenty three of 25 respondents (92%) who were very dissatisfied with dental services reported that care was not available in the area. Surprisingly, only two respondents reported that this service was expensive without insurance. Two respondents reported insufficient staff or bad service to be an issue and an additional two reported wait times to be too long.

157

Lab Services: The majority of respondents (89%) expressed an opinion on lab services. A total of 34 respondents (9%) had never availed of the service and a further six of them (2%) expressed no opinion.

Figure 15: Lab Services

n = 325 Very dissatisfied (2%) Somewhat dissatisfied (3%) Neither satisfied nor dissatisfied (12%) Somewhat satisfied (24%) Very satisfied (59%)

Seven respondents (2%) reported being very dissatisfied with lab services. Two of them reported that care was not available in their area, and five reported that wait times were too long.

X-ray Services: A total of 61 respondents (17%) said that they don’t use the service and 5 (1%) reported no opinion.

Figure 16: X-ray Services

n = 299 Very dissatisfied (5%) Somewhat dissatisfied (2%) Neither satisfied nor dissatisfied (13%) Somewhat satisfied (25%) Very satisfied (55%)

158

A total of 16 respondents (5%) reported being very dissatisfied with x-ray services. Eleven of them reported that care was not available in their area, and two reported that travel time to gain access to this service is “just too much”. Five respondents reported that wait time was also an issue.

Home Care Services: A total of 264 respondents (72%) reported not using home care services and 26 (7%) had no opinion on the service.

Figure 17: Home Care Services

n = 75

Very dissatisfied (17%) Somewhat dissatisfied (3%) Neither satisfied nor dissatisfied (16%) Somewhat satisfied (13%) Very satisfied (51%)

Of the 75 respondents who reported using home care services, nine of them (17%) were very dissatisfied with home care services. Five respondents reported that care was not available in their area and one reported home care services as being poor service or having insufficient staff.

In the comments section, two respondents reported that finding someone to fill home care positions was very difficult. One respondent reported that it was difficult to get enough hours. Another respondent reported that home care services were being provided to people in the community who did not need them, and individuals who desperately needed services were not able to get any.

159

Personal Care Homes: A total of 273 respondents (75%) reported that they did not use this service, and a further 17 of them (5%) reported no opinion.

Figure 18: Personal Care Homes

n = 75

Very dissatisfied (5%) Somewhat dissatisfied (3%) Neither satisfied nor dissatisfied (9%) Somewhat satisfied (40%) Very satisfied (43%)

Of the 75 respondents who did have an opinion, 62 of them (83%) were at least satisfied with personal care homes. Four respondents reported being very dissatisfied with personal care homes. One respondent stated that care was not available in the area and two respondents stated that poor service or insufficient staff was problematic. One respondent shared an account of a personal care home that did not provide adequate nutrition to a member of their household. The family had to therefore supply fresh fruits and vegetables, as well as a refrigerator.

160

Nursing Homes: A total of 270 respondents (74%) did not use this service, and an additional 20 of them (5%) reported no opinion.

Figure 19: Nursing Homes

n = 75 Very dissatisfied (8%) Somewhat dissatisfied (7%) Neither satisfied nor dissatisfied (14%) Somewhat satisfied (36%) Very satisfied (35%)

Seven respondents (2%) reported being very dissatisfied with nursing homes. Two respondents reported that care was not available in their area, and three reported that they felt nursing homes provided poor service, or were insufficiently staffed.

Nurse Practitioners: A total of 233 respondents (64%) stated that they had not used this service, and an additional 18 of them (5%) had no opinion of nurse practitioners.

Figure 20: Nurse Practitioners

n = 114

Very dissatisfied (4%) Somewhat dissatisfied (1%) Neither satisfied nor dissatisfied (10%) Somewhat satisfied (23%) Very satisfied (62%)

161

Of the 114 respondents who did have an opinion of the service, 97 of them (85%) were either somewhat or very satisfied with the services offered by their nurse practitioner. Five respondents were very dissatisfied with this service. Two respondents noted that care was not available in their area and there was one report of poor or insufficient care. In the comments section, one respondent shared that communication breakdowns among caregivers had impeded blood work, and another respondent said that the nurse practitioner in the area did not respond to calls.

Community Health Nurses: A total of 145 respondents (40%) stated that they do not use this service, and eight (2%) said they had no opinion. Figure 21: Community Health Nurses

n = 212

Very dissatisfied (1%) Somewhat dissatisfied (1%) Neither satisfied nor dissatisfied (7%) Somewhat satisfied (19%) Very satisfied (72%)

Of the 212 respondents who expressed an opinion on community health nurses, 193 of them (91%) were somewhat or very satisfied. Of the three respondents who were very dissatisfied with community health nurses, one stated that care was simply not available in the area, and one reported poor service and insufficient staff. One respondent said that confidentiality was an issue, as the community health nurse working the respondent’s area, also resided there. Another comment was that the nurse simply wouldn’t attend to the needs of the patient, and would always send them to a doctor.

162

Child, Youth and Family Services A total of 296 respondents (81%) said that they did not use the service, and 24 (7%) reported no opinion.

Figure 22: Child, Youth and Family Services

n = 45

Very dissatisfied (9%) Somewhat dissatisfied (7%) Neither satisfied nor dissatisfied (18%) Somewhat satisfied (22%) Very satisfied (44%)

Of the 45 individuals who expressed an opinion, 30 of them (66%) were satisfied with Child, Youth and Family Services. Two respondents said that care was not available in their community. Three respondents gave comments with one respondent saying that they wouldn’t even know whom to call for services; one reported that the workers are “not doing their job”. One complaint was made with specific reference to the recent Turner case; this respondent said there was simply not enough care.

163

Addictions Services: A total of 286 respondents (78 %) reported that they did not use this service, and 40 (11%) reported that they had no opinion.

Figure 23: Addictions Services

n = 40

Very dissatisfied (40%) Somewhat dissatisfied (13%) Neither satisfied nor dissatisfied (13%) Somewhat satisfied (13%) Very satisfied (22%)

Of the 40 individuals who did rate addictions services, 16 of them (40%) reported that they were very dissatisfied with this service. The most common complaint (by 11 of 16 respondents) was that care was not available in their area. Two respondents reported that service was poor or that staffing for this service was insufficient, and one respondent reported that wait times were too long. In the comments section, one respondent said that the service was offered in her community, but as it was not advertised; “no one knew it existed”.

164

Mental Health Services: A total of 271 respondents (74%) reported not having used this service, and an additional 22 of them (6%) gave no opinion.

Figure 24: Mental Health Services

n = 72

Very dissatisfied (31%) Somewhat dissatisfied (8%) Neither satisfied nor dissatisfied (22%) Somewhat satisfied (14%) Very satisfied (25%)

Of the 72 respondents who expressed an opinion, 22 (31%) reported they were dissatisfied with mental health services, with the most common complaint being that care was not available in their area. Three respondents mentioned that wait times were a problem, and one respondent reported that poor or insufficient staff was a problem. In the comment section, four respondents made reference to the lack of services and information for health consumers suffering from depression. One respondent reported the shortage of doctors in this field as a problem. One respondent questioned the safety of mental health consumers at the Waterford hospital, as a relative had allegedly been assaulted while they had been a patient there. Three respondents mentioned that information on available services and locations of service was difficult to obtain.

165

Services like Physiotherapy, Occupational Therapy and Dietitians: A total of 213 respondents (58%) reported not using any of these services, and 15 (4%) had no opinion.

Figure 25: Services like Physiotherapy,

n = 137

Occupational Therapy and Dietitians Very dissatisfied (18%) Somewhat dissatisfied (5%) Neither satisfied nor dissatisfied (11%) Somewhat satisfied (26%) Very satisfied (40%)

A total of 24 respondents (18%) of the 130 who had an opinion, reported being very dissatisfied with services like physiotherapy, occupational therapy and dietitians. Seventeen respondents reported that care was not available in their area and five reported that wait times were too long. In the comments section, two respondents reported that travel time was too long, and one respondent reported that physiotherapy services were too expensive without insurance, (in the absence of a referral from the doctor).

166

Support Services for People with Disabilities: A total of 259 respondents (71%) reported they didn’t use this service and 22 (6%) reported no opinion.

Figure 26: Support for People Living

n = 84

With Disabilities Very dissatisfied (24%) Somewhat dissatisfied (11%) Neither satisfied nor dissatisfied (14%) Somewhat satisfied (21%) Very satisfied (30%)

Fifteen of the 21 respondents (71%) who reported being very dissatisfied with support services for people with disabilities reported that no care was available in their area, and two respondents reported that care was poor or that the service was insufficiently staffed. Seven respondents provided comments on mental health services. Six respondents stated that there was not enough care available and that patients don’t get the services they need, and three said there was not enough support. There was also a comment regarding the lack of support groups for family members supporting individuals living with a disability.

167

Health Service Priority Respondents were then asked to name the number one health service priority for their area, from the list of services they had commented on. Their responses are presented in Table 15, with cross tabulations by region. Only the top five reported priorities are recorded. Â&#x2122;

A total of 61 respondents (17%) stated that they did not know which service should be the priority in their area. This was the second most frequently given response. Table 15: Service priority by region Service Family doctors

Frequency 123

Emergency service (hospital) Home care services

Ambulance services

Mental Health services

REGION A 31 25 % 19 16 % 4 3% 9 7% 2 2%

REGION B 52 50 % 5 5% 3 3% 2 2% 5 2%

REGION C 40 29 % 21 15 % 9 6% 5 4% 7 5%

Â&#x2122; Fifty-two respondents (50%) living in region B reported that family doctors should be the number one priority in their area. Â&#x2122; Respondents in both Region A and Region C identified family doctors and emergency services at the hospital as the main concerns in their areas.

168

Section 3: Community Health Challenges

169

Health and Community Issues Respondents were presented with a list of issues which may affect the health and well-being of people within the community and were asked to rate, on a scale of 1 to 5, with 1 being "Not a problem”, 3 being “Somewhat of a problem” and 5 being "A major problem", the extent to which they think these issues are a problem in the community. An examination of the table which follows shows that at least 30 per cent of those interviewed indicated that water pollution, housing conditions, car accidents, sexually transmitted diseases, water/sewer services, violence in the home, wheelchair access, teenage pregnancy, suicide and suicidal thoughts, crime in the community, recreational vehicle accidents, prescription drug abuse, poverty, poor reading and writing skills, lack of public transportation, low levels of education, and day care options are “Not a problem” in their community. Conversely, at least 30 per cent of those interviewed indicated that out-migration, road conditions, unemployment, cancer, lack of recreational facilities, lack of financial services, smoking, and day-care options are “A major problem” in their community. 1

Count %

Chronic illness

24 7%

16 4%

143 39 %

36 10 %

107 29 %

39 11 %

Cancer

29 8%

11 3%

101 28%

36 10%

174 48%

14 4%

Violence in the home

172 47%

25 7%

53 14%

5 1%

106 29%

Teenage pregnancy

162 44%

38 11%

84 23%

15 4%

17 5%

49 13%

Car accidents

188 52%

49 13%

83 23%

13 4%

17 5%

15 4%

Drunk driving

93 25%

32 9%

121 33%

28 8%

56 15%

35 9%

ATV, snowmobile, and motocross accidents

140 38%

26 7%

120 33%

26 7%

41 11%

12 3%

Sexually transmitted diseases

178 48%

23 6%

28 8%

7 2%

4 1%

124 34%

Depression or other mental health conditions

95 26%

37 10%

122 33%

21 6%

31 9%

58 16%

Suicide and suicidal thoughts

160 44%

33 9%

84 23%

16 5%

10 3%

61 17%

Maintaining a healthy diet

47 13%

18 5%

134 37%

52 14%

92 25%

23 6%

Illegal drug use

77 21%

17 5%

94 26%

36 10%

80 22%

Table 16: Health and Community Issues

170

61 17%

Table 16: Health and Community Issues (Continued)

Count %

Prescription drug abuse

132 36%

33 9%

56 15%

15 4%

18 5%

112 31%

Obesity or weight issues

58 16%

15 4%

153 42%

43 12%

81 22%

14 4%

Smoking

29 8%

27 7%

118 32%

38 10%

138 38%

15 4%

Gambling

102 28%

21 6%

99 27%

32 9%

61 17%

50 14%

Loneliness

66 18%

26 7%

126 34%

30 8%

77 21%

40 11%

Housing conditions

211 58%

38 11%

65 18%

10 3%

16 4%

25 7%

Lack of financial services

99 27%

24 6%

74 20%

22 6%

138 38%

8 2%

Lack of recreational facilities

52 14%

14 4%

104 29%

33 9%

156 43%

5 1%

Lack of recreational / social activities

69 19%

18 5%

122 33%

36 10%

106 29%

14 4%

Water / sewer services

177 48%

20 5%

54 15%

25 7%

78 21%

13 4%

Air or water pollution

222 61%

28 8%

52 14%

20 5%

22 6%

20 6%

Lack of public transportation

115 32%

27 7%

90 25%

24 7%

96 26%

12 3%

Road conditions

47 13%

15 4%

73 20%

32 9%

196 54%

3 1%

Wheelchair access

168 46%

39 11%

94 26%

18 5%

24 7%

20 6%

Poor reading and writing skills

120 33%

35 9%

108 29%

18 5%

66 18%

Low levels of education

115 32%

36 10%

197 37%

18 5%

24 6%

36 10%

Out-migration

24 7%

9 2%

41 11%

34 9%

250 68%

7 2%

Unemployment

25 7%

14 4%

83 23%

40 11%

193 53%

10 3%

Marital difficulties

87 87%

37 10%

113 31%

16 4%

18 5%

95 26%

Poverty

13 36%

55 15%

115 32%

18 5%

29 8%

18 5%

Crime

146 40%

57 16%

101 28%

20 6%

33 9%

7 2%

171

Table 16: Health and Community Issues (Continued)

172

Count %

Lack of parenting training / support groups

82 22%

19 5%

88 24%

34 9%

71 19%

Daycare options

108 29%

22 6%

64 18%

20 5%

109 30%

42 12%

Lack of health services for teenagers

96 26%

19 5%

84 23%

32 9%

54 15%

79 22%

Availability of support for the elderly

102 28%

31 8%

103 28%

27 8%

74 20%

27 7%

Lack of support groups

80 22%

23 6%

84 23%

29 8%

105 29%

43 12%

Section 4: Personal Health and Wellness

173

Physical Health: Â&#x2122; Respondents tended to rate their health as good, very good or excellent (71%) more frequently than fair and poor (29%). Table 17: How would you rate your own physical health, in general? Frequency 34 125 102 77 27 365

Excellent Very Good Good Fair Poor Total

Per cent 9 34 28 21 8 100

Number of Respondents

Figure 27: Respondents rating their physical health

60 50 40 30 20 10

Region A Region B Region C

0 Poor

Fair

Good

Very Good Excellent

Â&#x2122; There was no significant difference among regions, in how respondents rated their physical health (p = 0.896).

174

Mental Health: A total of 331 respondents (90%) rated their mental health as good or better. Table 18: How would you rate your own mental health? Frequency 92 129 110 30 4 365

Excellent Very Good Good Fair Poor Total

Per cent 25 35 30 8 2 100

Less than 10 per cent of respondents reported having poor or fair mental health.

Number of Respondents

Figure 28: Respondents rating their mental health

60 50 40 Region A

Region B

Region C

10 0 Poor

Fair

Good

Very Good Excellent

No respondents in Region A reported having poor mental health, while three respondents in Region B, and one respondent in Region C reported having poor mental health.

175

Social Support: Â&#x2122; Respondents reported having good support systems or better, more frequently than any of the lower classifications (see Table 19). Table 19: How would you rate the social support you have in your area â&#x20AC;&#x201C; number of friends / family? Frequency

Per cent

106 100 123 26 9 1 365

29 27 34 7 3 <1 100

Excellent Very Good Good Fair Poor Refused Total

Number of Respondents

Figure 29: How would you rate the social support you have in your area?

60 50 40

Region A

Region B Region C

20 10 0 Poor

176

Fair

Good

Very Good

Excellent Refused

Diet (Fruit and Vegetable Consumption): When asked if they usually ate at least five servings of fruits and vegetables a day, 232 of respondents (64%) said they did not, and four respondents (1%) said they did not know. Table 20: Do you usually eat five servings of fruits and vegetables daily? REGION A REGION B REGION C Frequency Per cent Frequency Per cent Frequency Per cent Yes 45 37 34 33 49 35 No 74 61 69 67 90 64 Don’t Know 3 2 0 0 1 1 Total 122 100 103 100 140 100

There was no significant relationship between fruit and vegetable consumption and the region in which the respondent was located (p = 0.411). Of the 181 respondents in the yearly income brackets of $10,000 up to less than $40,000, a total of 35 per cent of them reported that they usually ate five servings of fruits and vegetables a day. Of the 71 respondents in the yearly income brackets of $40,000 up to less than $80,000, a total of 37 per cent of them reported that they usually ate five servings of fruits and vegetables a day. At the highest income bracket of $80,000 and up, 47 per cent of them (16 of 34 respondents) reported consuming five servings of fruits and vegetables daily.

Smoking: Of the 365 respondents, only 74 of them (20%) reported smoking cigarettes daily. Table 21: Do you currently smoke cigarettes daily? REGION A REGION B Frequency Per cent Frequency Per cent Yes 24 20 23 22 No 98 80 80 78 Don’t 0 0 0 0 Know Total 122 100 103 100

REGION C Frequency Per cent 27 19 112 80 1 1 140

100

Although not significant (p = 0.836), a slight trend existed between income and smoking. Lower income households tended to report smoking daily at a higher frequency than did households with higher incomes. For example, of the 15 respondents who were in the income bracket of less than $10,000, five of them (33%) were smokers, while only seven of the thirty-three respondents (21%) with an income of $80, 000 or more reported smoking daily.

177

Gambling: For the purposes of this study, gambling includes scratch ’n win tickets, lottery tickets, break-open tickets, video lottery terminals, card games, or bingo. A total of 28 respondents (8%) reported spending $20 or more on gambling ventures weekly. Table 22: Do you spend more than $20 per week on average on gambling? REGION A REGION B REGION C Frequency Per cent Frequency Per cent Frequency Per cent Yes 12 10 8 8 8 6 No 110 90 95 92 132 94 Total 122 100 103 100 140 100

There was no relationship between the respondent’s propensity to gamble and their location (p = 0.457). No clear relationship between gambling habits and household income could be established (p = 0.494).

Alcohol Consumption: Of the 365 respondents, 25 of them (7%) reported that they consumed seven alcoholic drinks per week on average. Table 23: Do you have more than seven alcoholic drinks, per week, on average? REGION A REGION B REGION C Frequency Per cent Frequency Per cent Frequency Per cent Yes 9 7 8 8 8 6 No 113 93 95 92 132 94 Total 122 100 103 100 140 100

There were no evident trends in alcohol consumption, either by region (p = 0.790) or by household income (p = 0.367).

178

Physical Activity: A total of 237 respondents (65%) reported they participate in physical activities lasting 20 minutes or longer at least 3 times per week (see Table 24). Table 24: Do you participate in physical activities lasting 20 minutes or longer, at least three times per week? Frequency Per cent Yes No Don't Know Total

237 122 6 365

65 33 2 100

Table 24a: Do you participate in physical activities lasting 20 minutes or longer, at least three times per week? REGION A REGION B REGION C Frequency Per cent Frequency Per cent Frequency Per cent Yes 75 62 75 73 87 65 No 46 37 26 25 50 33 Don’t Know 1 1 2 2 3 2 Total 122 100 103 100 140 100

No clear relationship between exercise and gender could be established (p = 0.537). Further analysis revealed that no relationship could be established between the respondent’s age and their propensity to exercise (p = 0.253). There was no significant variation (p = 0.279) in exercise between regions.

Health Question for Females: A total of 276 females took part in the survey.

179

Breast Exams: A total of 16 female respondents had never had a breast exam, and 11 of these respondents were located in Region C. There was no significant variation between regions, for the length of lapsed time since female respondent’s last breast exam (p = 0.436).

Figure 30: When was the last time you had a breast exam?

Less than 1 year (48%) One year to less than 3 years (29%) Five years or more (16%) Never (6%) Don’t Know (1%)

Table 25: When did you last have a breast exam by a doctor or a nurse? REGION A REGION B REGION C Frequency Per cent Frequency Per cent Frequency Per cent Less than 1 year 48 50 42 52 44 44 One year to less 27 28 26 32 27 27 than 3 years Five years or more Never Don’t Know Total

180

17 3 1 96

18 3 1 100

9 3 0 80

11 4 1 100

18 10 1 100

Mammograms: A total of 89 females polled (32%) reported never having had a mammogram.

Figure 31: When was the last time you had a mammogram?

Less than 1 year (36%)

One year to less than 3 years (21%) Three years or more (11%) Never (32%)

Table 26: When did you last have a mammogram? REGION A REGION B REGION C Frequency Per cent Frequency Per cent Frequency Per cent Less than 1 year 30 31 33 41 35 35 One year to less than 3 23 24 21 26 14 14 years Five years or more Never Total

10 33 96

10 35 100

8 18 80

10 23 100

13 38 100

There was no significant difference among regions in the latency period between respondents’ last mammogram (p = 0.175).

181

Cervical Cancer Screenings: A total of 175 female respondents (63%) reported having been screened for cervical cancer (pap smear) within the past three years. Figure 32: When was the last time you had a pap test? Less than 1 year (41%) One year to less than 3 years (23%) Three years or more (32%) Never (3%) Do not know (1%)

Table 27: When did you last have a pap test? REGION A REGION B REGION C Frequency Per cent Frequency Per cent Frequency Per cent Less than 1 year 43 45 39 49 32 32 One year to less than 3 20 21 15 19 26 26 years Five years or more Never Don’t Know Total

30 3 0 96

31 3 0 100

22 4 0 80

27 5 0 100

38 2 2 100

No relationship could be established between the region and the last time the respondent had a pap test (p = 0.221). There was a significant relationship between age and when the respondent was last screened for cervical cancer (p = 0.005). Younger females tended to have a shorter latency period since their last pap test, than did older females. There was a significant relationship between household income and the length of time elapsed since the respondent’s last cervical cancer screening (p = 0.004). Females living in lower income households tended to report having had a pap smear longer ago than reportedly more affluent households.

182

Health

Question for Males:

A total of 89 males took part in the survey.

Prostate cancer:

A total of 57 male respondents (65%) reported having been checked by a doctor for prostate cancer, in the last year.

Table 28: Have you ever been checked by a doctor for prostate cancer? REGION A REGION B REGION C Frequency Per cent Frequency Per cent Frequency Per cent Yes 17 62 15 65 25 66 No 9 34 7 31 13 34 Refused 1 4 1 4 0 0 Total 27 100 23 100 38 100

A total of 29 male respondents (33%) indicated that they had never been screened for prostate cancer.

Further analysis revealed that there was a significant relationship between the respondent’s age and whether or not they had been checked for prostate cancer (p = 0.00). With the exception of one male aged 20 years old, all other males under the age of 36 and over the age of 85 had never had this screening.

A total of 32 of the 57 males (56%) who reported having the test indicated having the procedure within the last year.

Figure 33: When was the last time you had this test?

Less than 1 year ago (56%) One year to less than 3 years ago (30%) Three years or more (14%)

183

Further analysis revealed no relationship between the age of the respondent and the length of time since their last prostate exam (p = 0.937).

Table 29: When did you last have this test (prostate examination)? REGION A REGION B REGION C Frequency Per cent Frequency Per cent Frequency Per cent Less than 1 year 8 50 8 50 16 64 ago One year to less than 3 years ago Three years or more Total

100

Overall Satisfaction with Health and Social Programs

When asked if they thought health and social programs in their area were staying the same, getting better, or getting worse, 182 respondents (50%) said they felt they were staying the same (see Table 30). Table 30: Do you think health and social programs in your area are...?

Getting better Staying the same Getting worse No opinion Total

Frequency

Per cent

85 182 69 30 365

23 50 19 8 100

Table 30a: Do you think health and social programs in your area are...? REGION A REGION B REGION C Frequency Per cent Frequency Per cent Frequency Per cent Getting 38 31 24 23 23 17 better Staying the 63 52 53 52 67 48 same Getting 11 9 23 22 34 24 worse No opinion 10 8 3 3 16 11 Total 122 100 103 100 140 100

184

There was a significant relationship between household income and how respondents thought the health and social programs in their area were faring (p = 0.00). Respondents with higher household earnings tended to rate the programs as getting better, while lower income households tended to rate the programs as getting worse.

Â&#x2122;

Further analysis revealed a significant relationship between the respondentâ&#x20AC;&#x2122;s age and their views on health and social programs in their area (p = 0.00). Older respondents indicated that they had no opinion or thought that the health and social programs were getting better with more frequency than did younger individuals, who more frequently reported that they felt these programs were getting worse.

Â&#x2122;

There was also a significant relationship between the gender of the respondent and their views on health and social programs (p = 0.00). Eighteen percent of female respondents reported that they thought health and social programs were getting better, while only two percent of male respondents made that conclusion.

185

Complete List of Secondary Resource Materials

186

Secondary Resource Materials Allen, Elizabeth Dow (2003). Caregivers: “Out of Isolation” Final Evaluation Report. Seniors Resource Centre of Newfoundland and Labrador. Baikie, Peggy R. (2003). Child Care Services Needs Assessment Newfoundland and Labrador, Final Report. Child Care Services Needs Assessment Advisory Committee and the Department of Health and Community Services. Cavanagh, Sue and Chadwick, Keith (2005). Summary: Health Needs Assessment at a Glance. Health Development Agency. Canadian Institute for Health Information (2006). Health Indicators. Canadian Institute for Health Information (2006). Health Care in Canada. Canadian Institute for Health Information, Canadian Population Health Initiative (2004). Improving the Health of Canadians. Canadian Institute for Health Information, Canadian Population Health Initiative (2006). How Healthy are Rural Canadians? Chinook Health Region (n.d.) The Determinants of Health. Committee on Public Health Capacity (2004). Investing in Health; a Report on Public Health Capacity in Newfoundland and Labrador. Dietitians of Newfoundland and Labrador, Newfoundland and Labrador Public Health Association, Newfoundland and Labrador Association of Social Workers (2004). The Cost of Eating in Newfoundland and Labrador – 2003; a discussion paper. Department of Corporate Strategy and Research (Eastern Health) and The Telelink Call Centre (St. John’s). (2007). Southern Avalon Needs Assessment Telephone Survey Report. Eastern Health and Community Services Board (2002). Health in Our Community; a Profile of the Eastern Region. Eastern Health and Community Services Board (2004). Healthy People, Healthy Communities, Healthy Future: Health Promotion Plan 2004-2007. Eastern Health and Community Services Region and Local Public Health Infrastructure Development (LoPHID) Project (2001). Dialogue on Heart Health. Eastern Health and Community Services Region and Local Public Health Infrastructure Development (LoPHID) Project. (2000). Examining Prenatal Services. Eastern Health and Community Services Board and Local Public Health Infrastructure Development (LoPHID) Project. (2002).The Burden of Care: Caregiver Stress and Community Supports. Eastern Health and Community Services Board (2001-02). Evaluation of Model for the Delivery of School-Based Services: Phase 1 – Year 1 (2001-02).

187

Eastern Regional Integrated Health Authority (2007). Development of a Service Delivery and Infrastructure Plan for the Delivery of Long Term Care Services in the Northeast Avalon Area. Eastern Regional Integrated Health Authority (2006). Navigating the Way Together: Burin Peninsula Community Health Needs Assessment. Eastern Regional Integrated Health Authority (2006) Strategic Plan. Eastern Regional Integrated Health Authority and Joint Mental Health and Addictions Services Planning Group (2005). Working Together for Mental Health – A Regional Action Plan for Eastern Health. Frankish, C. James et al (2007). Addressing the Non-medical Determinants of Health; a Survey of Canada’s Health Regions. Canadian Journal of Public Health January-February 2007. Gaining Ground: A Cancer Control Strategy for Newfoundland and Labrador (November 2006). Executive Committee and Working Groups for the Development of a Provincial Cancer Control Strategy. Gien, Dr. Lan (Principle investigator) et al. (2005). Natural Resource Depletion and Health. Project Summary presented at a Community Forum in St. John’s, May 6-7, 2005. Government of Newfoundland and Labrador, Department of Health and Community Services (2005). Newfoundland and Labrador Gambling Prevalence Study. Government of Newfoundland and Labrador, Department of Finance, Economics and Statistics (2005). Demographic Change: Newfoundland and Labrador – Issues and Implications. Government of Newfoundland and Labrador, Department of Health and Community Services (2003). Moving Forward Together: Mobilizing Primary Health Care. Government of Newfoundland and Labrador, Department of Human Resources, Labour and Employment (2006). Reducing Poverty: An Action Plan for Newfoundland and Labrador. Government of Newfoundland and Labrador, Department of Health and Community Services (2006). Achieving Health and Wellness: Provincial Wellness Plan for Newfoundland and Labrador (Phase 1: 2006-2008). Government of Newfoundland and Labrador, Newfoundland and Labrador Statistical Agency. Community Accounts (http:www.communityaccounts.ca) Hancock, Trevor (2001). Moving Beyond Healthcare: The Role of Healthcare Organizations in Creating Healthy People in Healthy Communities in a Healthy World. Hospital Quarterly, Summer 2001. Hay, David I. (2006). Economic Arguments for Action on the Social Determinants of Health. Public Health Agency of Canada and Canadian Policy Research Networks Inc. Hay, David, Varga-Toth, Judi and Hines, Emily (2006). Frontline Health Care in Canada: Innovations in Delivering Services to Vulnerable Populations. Canadian Policy Research Networks. Hayward, Karen and Coleman, Ronald (2003). The Tides of Change: Addressing Inequity and Chronic Disease in Atlantic Canada, a discussion paper. Population and Public Health Branch, Atlantic Region Offices, Health Canada.

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Health and Community Services St. John’s and Memorial University of Newfoundland School of Nursing, Department of Psychology (2001). A Summary Report on the Community Health Needs and Resources Assessment of the St. John’s Region. Health Canada (2007). Why Health Care Renewal Matters: Lessons from Diabetes. Health Canada (2006). Their Future is Now: Healthy Choices for Canada’s Children and Youth. Health Disparities Task Group of the Federal/Provincial/Territorial Advisory Committee on Population Health and Health Security. (2005). Reducing Health Disparities – Roles of the Health Sector: Recommended Policy Directions and Activities. Housing Policy Working Group (n.d.) A Housing Strategy for Newfoundland and Labrador. Johns, Annette and Lush, Gail (2004). Adolescent Sexual Decision-Making in Newfoundland and Labrador. Planned Parenthood Newfoundland and Labrador and the Women’s Health Network, Newfoundland and Labrador. Kilbride to Ferryland Family Resource Centre. Annual Report 2005-06, Kilbride to Ferryland Family Resource Centre Coalition Inc. Maxwell, Judith (2006). Looking Down the Road: Leadership for Canada’s Changing Communities. Discussion paper prepared for the Community Foundations of Canada. Mustard, Cameron, Tompa, Emile and Etches, Jacob (2006).The Effects of Deficits in Health Status in Childhood and Adolescence on Human Capital Development in Early Adulthood. Canadian Policy Research Networks. Muzychka, Martha (2006). Developing a Provincial Oral Health Plan: Go Healthy – Keep Smiling! Department of Health and Community Services, Stakeholder Consultation Report. Newfoundland and Labrador Centre for Health Information. (2006). Fast Facts: Hospital Utilization. Newfoundland and Labrador Centre for Health Information (2006). Fast Facts: Mortality Statistics. Newfoundland and Labrador Centre for Health Information (2006). Fast Facts: Tobacco Use. Newfoundland and Labrador Centre for Health Information (2006). Survey Says: A Report on Selected Health Indicators, Canadian Community Health Survey 2003. Roebothan, Barbara V. (2003). Nutrition Newfoundland and Labrador: The Report of a Survey of Residents of Newfoundland and Labrador, 1996. St. John’s, Newfoundland: Department of Health and Community Services, Province of Newfoundland and Labrador. Scott, Katherine and Lessard, Richard (n.d.) Income Inequality as a Determinant of Health. Summary based on papers and presentations prepared for The Social Determinants of Health across the Life-Span Conference, November 2002. Stepping Stones Family Resource Centre. Annual Report 2005-06, Stepping Stones Family Resource Centre. Social Work Workload Committee, Community Living and Supportive Services, Health and Community Services St. John’s Region (2006). Community Living and Supportive Services Workload Concerns.

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Statistics Canada (2007). Cancer Incidence in Canada (2003 to 2004), Second edition. Westara, Doreen, Bennett, Lorna and Dawe, Doreen (2004). Project Teen Newfoundland and Labrador: A Comprehensive Study.

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Listing of Eastern Health Staff Consulted on Issues Arising From the Community Health Needs Assessment

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Listing of Eastern Health Staff Consulted on Issues Arising From the Community Health Needs Assessment Judy O’Keefe, Director of Integrated Health Services, Long Term Care and Supportive Services, Rural Avalon Ann Mercer, Director of Community Living and Supportive Services Ann Manning, Director of Community Health and Nursing Services Natalie Moody, Director of Health Promotion Diane Reid, Facility Manager, Placentia Health Centre Doris Lewis, Manager, Community Health Nursing, Rural Avalon Judy Power, Director, Primary Health Care Lynn Wade, Manager of Client Services, Laboratory Medicine Olive Walsh, Manager, Community Supports, Rural Avalon Evelyn Tilley, Manager, Mental Health and Addictions, Rural Eastern Janice Dalton, Manager, Allied Health and Community Supports (Seniors), Rural Avalon Mary Cahill, Manager of Environmental Health Cal Morgan, Manager of Environmental Health, Rural Eastern Moira O’Regan-Hogan, Manager, Community Health and Nursing Services Mary Rossiter, Social Worker – Community Supports Corey Banks, Division Manager, Paramedicine and Emergency Transport Roy Dawe, Manager of Planning and Engineering Support, Infrastructure Support Mary Manojlovich, Professional Practice Coordinator - Occupational Therapy and Occupational Therapists Jeff Williams, Mary Harris, Sarah Lawrence, Jennifer Clarke, June Walter-Wilson, Krista Thorne and Shelley Di-Nur.

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Newsletters Circulated During the Community Health Needs Assessment

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A community health needs assessment gathers information about the health of a particular area using facts and opinions. The information is analyzed, issues are identified and recommendations for action are formed.

Eastern Health believes that communities have the strengths, knowledge and skills necessary to develop programs which will influence the determinants of health and promote healthy living.

If you’re called for the phone survey, take the opportunity to tell us what you see as issues and challenges, as well as the good news stories about healthcare in your area.

Southern Avalon Community Health Needs Assessment November 2006

What Is A Community Health Needs Assessment? A community health needs assessment looks at the factors that determine the health of a community, from income and education, to physical and social environments. The Southern Avalon Needs Assessment is the second needs assessment being undertaken by Eastern Health. In June 2006, Navigating the Way Together— Burin Peninsula Community Health Needs Assessment was released. This report is available on Eastern Health’s website http://www.easternhealth.ca

Information is being collected through interviews, focus groups and document review. Phone surveys will begin the first week of December. If you are called, please take the time to participate in the survey. This is your chance to tell us vital information about your community’s health needs.

Once the Southern Avalon Needs Assessment is completed, it will become an extremely useful tool that can be used by individuals, communities and organizations to decide how to work on enhancing the health of communities for years to come.

For more information, contact: Jane Macdonald, Planning Specialist, Eastern Health SM 137, St. Clare’s Mercy Hospital 154 LeMarchant Rd. St. John’s, NL A1C 5B8 (709) 777-5229

The areas being reviewed are: Southern Avalon from Bay Bulls along the Irish Loop to St. Shott’s, around St. Mary’s Bay and along the east side of Placentia Bay to Long Harbour-Mount Arlington Heights.

jane.macdonald@easternhealth.ca

Local Advisory Committee An Advisory Committee made up of individuals from the Southern Avalon region has been set up. This group meets regularly and will offer input and feedback throughout the needs assessment process.

Front row: (l to r) Elaine Murray, Placentia; Lorelei Roberts-Loder, Placentia; Rita Pennell, Trepassey; Tony Healey, St. Joseph’s; Back Row (l to r) Diane Costello, Ferryland; Sherry Walsh, North Harbour; Maxine Gregory, Harricott. Missing: Wayne Miller, Senior Director, Corporate Strategy and Research

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The Determinants of Health Using the Health Determinants Model Health is more than just doctors, hospitals and diseases. Your health as well as that of your community depends on many things, from income and working conditions to social environments, healthy personal practices and education. These factors are known as the determinants of health.

The Determinants of Health are: physical environments

income and social status

personal health practices and coping skills

employment and working conditions

healthy child development

social support networks

biology and endowment

Fall Day

education

Near Renews

health services

social environments

gender and culture

Understanding what will make you healthier—that’s what the Southern Avalon Needs Assessment is all about.

“Quote from Hubert McGrath xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

Why Undertake A Health Needs Assessment?

”

The Board of Trustees of Eastern Health has identified community health needs assessments throughout the region as a priority for the organization. These assessments help us better understand what a community feels it needs in order to be healthier. They give us an

Father Val Power Learning Centre , Riverhead, St. Mary’s Bay

opportunity to talk with and listen to many community groups and individuals. Understanding the needs of our communities is important because it provides Eastern Health with the kind of solid information we need to work toward our vision of Healthy People, Healthy Communities.

“With the emphasis changing from a reactive approach to a proactive and preventative approach to healthcare, it is good to see that Eastern Health is asking its various publics to speak out on where and how they see healthcare moving in the future,” says Hubert McGrath, Eastern Health Board Member. “I would encourage a high level of involvement by participants because the results of this exercise can provide valuable information for the planning and decision-making which will take healthcare into the future.”

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Eastern Health believes that communities have the strengths, knowledge and skills necessary to develop programs which will influence the determinants of health and promote healthy living.

“If we truly are to make a difference in the health of our communities and their residents it is essential that we gain an understanding of the issues that affect peoples’ health to identify where we can have the greatest overall impact.” George Tilley, Eastern Health C.E.O.

Southern Avalon Community Health Needs Assessment JANUARY 2007

What’s Happening So Far? Focus Groups and Key Informant Interviews The fall period was a busy time for collecting information - 16 focus group meetings were held on the Southern Avalon and 44 key informant interviews took place. These discussions helped to focus the needs assessment; they identified some key themes. Focus groups were held with representatives of community organizations, municipalities, community advisory committees (primary health care), seniors, service providers, the Placentia physician group, and partners of Eastern Health. The focus

group discussions were lively and lots of suggestions and ideas came forward. Thanks to all those who participated! Key informants have a broad overview of the area or of specific health and community service-related needs. They were asked to reflect on community strengths, challenges and needs and provide suggestions for improving health and wellness in the area. Telephone Survey A random telephone survey was conducted by Telelink Inc. in early December, including 365 interviews. People were surveyed

Next Steps

on a number of questions about health services, including access to service, health and community problems faced by their community, personal health and wellness habits and demographic information. Thanks to all who participated in the telephone survey and provided valuable information – the surveyors report good cooperation. Call for Submissions The public were asked to let us know any ideas or opinions they had on the health-related needs of their communities. Several submissions have been received.

Branch

Eastern Health is now reviewing all the information collected in the first stage of the assessment (key informant and focus group interviews, telephone survey data, written submissions), along with information in other research reports. We’re collecting information about how health and community services in the area are being used, including wait list information. Population trends, the economic outlook and anything else that will help us look at the challenges facing the Southern Avalon area will be reviewed. We’re looking at success stories – how communities are coming together to meet their needs and promote health and wellness. Together with the Steering and Advisory Committees, we will identify issues, select priorities, and develop an action plan.

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The Determinants of Health are: physical environments

income and social status

personal health practices and coping skills

employment and working conditions

healthy child development

social support networks

biology and endowment gender and culture

education

health services

social environments

Looking Closer: Social Support Networks If we live in a community where we get support - from our family, friends and from the community itself, we are more likely to have better health. Just think about it for a minute. When you have support from friends during a challenging time in your life, don’t you feel better about your situation? This social support has been proven to play a key role in promoting and maintaining good health. In the Southern Avalon region, out-migration is challenging the social support networks that have traditionally sustained people. As many people move outside the community and the province for employment, those remaining (a large number of whom are seniors) may be left without the social support networks they have traditionally depended upon. They may have fewer immediate family members nearby should they need help with home repairs, transportation to buy groceries, visit the clinic or get out to social events, or just a visit to pass the time and have the joy of human contact. Caring for each other has always been a strength of the people of the Southern Avalon, but this tradition is being challenged as fewer people are left to support each other.

Ask yourself:

9 Who in my community is suffering because they have lost their social support network? 9 What can our community do to support them? 9 How can I help others who are struggling without a social support network?

Members of Trepassey 50 + at focus group discussion. (l-r) Marie Waddleton, Josephine Waddleton, Mary Perry

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Eastern Health believes that communities have the strengths, knowledge and skills necessary to develop programs which will influence the determinants of health and promote healthy living.

Southern Avalon Community Health Needs Assessment MARCH 2007

Our Progress – Keeping you Informed In January and February 2007, the Steering Committee and Community Advisory Committee for the Southern Avalon Community Health Needs Assessment reviewed the findings of the primary research. This research included key informant interviews, focus group discussions, and a telephone survey. Emerging themes were discussed and the findings were confirmed. The report, along with recommendations, is now being drafted. Eastern Health’s Executive Team will review the draft community health needs assessment report in early April and the report will be reviewed and discussed by the Board of Trustees in late April. Preparations for public release will occur in May and the release of the report is anticipated for June 2007.

“We all need to work together to meet the challenges of living in rural Newfoundland.” Key Informant

“Although the population has declined...the older population has remained. Providing services to these people will be a challenge considering their limited mobility, reduced financial capacity and their isolation.” Written Submission

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The Determinants of Health Health is more than just doctors, hospitals and diseases. Your health as well as that of your community depends on many things, from income and working conditions to social environments, healthy personal practices and education. These factors are known as the determinants of health. The Determinants of Health are: income and social status employment and working conditions social support networks education social environments

physical environments personal health practices and coping skills healthy child development biology and endowment gender and culture health services

This newsletter takes a closer look at four of the determinants of health. As you read about these influences on health ask yourself: • •

How is this determinant of health influencing the health and well-being of people in my community? What can we, as a community, do about this?

Healthy Child Development Many of these personal health practices and coping skills are based on habits that began in childhood—this indicates the life-long importance of healthy child development. A healthy and happy baby is more likely to grow up to be a healthy and happy adult.

Personal Health Practices and Coping Skills People can take individual actions to support health and wellness, such as regular exercise, watching what they eat, and not smoking. They can also develop healthy coping skills to help them deal with life’s stressful events.

Income and Social Status It’s difficult to be healthy when you are living on a low income. Your income often determines your living conditions, such as whether you have safe housing or can purchase healthy food. An adequate income gives people more choice and more control in their lives. In Canada, people with lower incomes often have poorer health.

Employment and Working Conditions Income is often related to employment. People with stable jobs have better incomes and may have better selfesteem and more opportunities for social support than someone who is unemployed. Jobs that are unstable or seasonal can often cause stress which impacts on health.

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Geographic Overview of Health Services Offered on the Southern Avalon

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Long Term Care Protective Care Respite Care ¥ ¥

¥ (4 salaried physicians at PHC; 2 feefor-service physicians in the community)

¥ (9 beds) ¥ (1 bed) ¥

Placentia Health Centre

Nurse Practitioner

Emergency Room Family Practice Clinics

Palliative Care

Acute Care

Services

Placentia Public Building (Court House)

¥ (shared service - St. Mary’s)

¥ ¥ (1 salaried (coverage physician) provided by St. Mary’s physician – 1 day/week)

St. Bride’s St. Mary’s Mt. Carmel Bay Health Health Health and Centre * Centre Community Services Office

St. Joseph’s Council Building

¥ (1 fee-forservice physician located in Nurse Abernathy clinic)

¥ ¥ (2 salaried 3 fee-forphysicians) service physicians are located in Bay Bulls in the pharmacy building

Trepassey - Ferryland - Witless Bay Health and Shamrock Health and Community Community Clinic, Services Services Health and Office Community Office, Services Abernathy Office Clinic

(*Note – at the time of the community health needs assessment, health services at St. Mary’s Health Centre were in the process of co-locating with health and community services, moving from two sites to one combined site at the St. Mary’s Bay Health Centre.)

Geographic Overview of Health Services Offered on the Southern Avalon

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Recreation Therapy Respiratory Therapy Physiotherapy Occupational Therapy Speech Language Pathology Specialty Clinics

provision of specific programs and services

Well Women, Well Men

on referral

¥ ¥

provision of specific programs and services

limited, from St. John’s limited, from St. John’s

provision of specific programs and services

limited, from St. John’s limited, from St. John’s

provision of specific programs and services

limited, from St. John’s limited, from St. John’s

provision of specific programs and services

Trepassey - Ferryland - Witless Bay Health and Shamrock Health and Community Clinic, Community Services Health and Services Office, Community Office Abernathy Services Clinic Office ¥ ¥

¥ (limited)

St. Joseph’s Council Building

¥ ¥ ¥ ¥

¥ (limited)

St. Bride’s St. Mary’s Mt. Carmel Health and Bay Health Health Community Centre * Centre Services Office

¥ (limited)

Blood Collection Services Laboratory Services Diagnostic Imaging: General X-ray Ultrasound Chemotherapy Social Work

Placentia Public Building (Court House)

Placentia Health Centre

Services

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Continuing Care (followup, acute/ chronic care) Health Promotion Health Protection ¥

service available in Placentia or Whitbourne ¥

service service available in available in Holyrood Holyrood

¥ biweekly clinic; case managmt. services from Holyrood

St. Bride’s St. Mary’s Mt. Carmel Health and Bay Health Health Community Centre * Centre Services Office

Placentia Public Building (Court House)

bi-weekly clinic, also service in Whitbourne ¥

Mental Health

Addictions

Placentia Health Centre

Diabetes Education Clinics Dietitian

Services

service available in Holyrood

limited, from Holyrood

St. Joseph’s Council Building

¥ see above

limited, from Monthly St. John’s clinics from St. John’s ¥ ¥ (1 day/wk) (1 day/wk)

Monthly clinics from St. John’s ¥ ( 3 days per week -– 1 position covers both Mental Health and Addictions – Witless Bay to St. Shott’s) ¥ see above

Trepassey - Ferryland - Witless Bay Health and Shamrock Health and Community Clinic, Community Services Health and Services Office, Community Office Abernathy Services Clinic Office

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Primary Health ¥ Care Renewal Initiative Cottages/NLH 40 (adjacent to PHC)

on referral from Whitbourne on referral from Whitbourne on referral from Hr. Grace or Clarenville

on referral – from Placentia

Behaviour Management Intervention Services Child Management Intervention Services Child Care Services

on referral – from Placentia

Community Youth Corrections Community Supports

on referral from Hr. Grace or Clarenville outreach from Placentia

on referral from Hr. Grace or Clarenville

on referral - on referral from from Holyrood Holyrood

on referral – from Ferryland on referral – from Ferryland on referral – from St. John’s

on referral from Ferryland

Witless Bay Health and Community Services Office

on referral on referral – on referral – on referral – from Hr. Grace from St. from St. from St. or Clarenville John’s John’s John’s

on referral on referral – on referral – on referral – from Holyrood from St. from St. from St. John’s John’s John’s

Trepassey Health and Community Services Office, Abernathy Clinic on referral on referral from Holyrood from Ferryland

St. Joseph’s Council Building

Ferryland Shamrock Clinic, Health and Community Services Office on referral - on referral ¥ from from covers Holyrood Holyrood Witless Bay to St. Shott’s on referral on referral – on referral – on referral – ¥ – from from from Holyrood from Witless Bay Holyrood Holyrood Ferryland to St. Shott’s on referral on referral – ¥ on referral ¥ – from St. from St. from Bay Bulls to Joseph’s Joseph’s Ferryland St. Shott’s on referral - on referral - on referral on referral – on referral – from from from Holyrood from St. from St. Holyrood Holyrood John’s John’s

St. Bride’s St. Mary’s Mt. Carmel Health and Bay Health Health Community Centre * Centre Services Office

on referral from Placentia

Placentia Public Building (Court House)

Placentia Health Centre

Child, Youth and Family Services

Services

Infrastructure Assessment, Southern Avalon

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Infrastructure Assessment, Southern Avalon Worksites As part of this community health needs assessment, Eastern Health’s Department of Infrastructure Support commissioned a review of the Eastern Health worksites on the Southern Avalon. This review was carried out between November 2006 and February 2007 by Newlab Engineering. Eastern Health conducted an on-site inspection and review of biomedical equipment at each site during the same time period. Several of these office locations are leased (Witless Bay, Ferryland, St. Mary’s, St. Joseph’s, and Mt. Carmel); several spaces are owned by the Department of Transportation and Works (St. Bride’s, Placentia Court House, Abernathy Clinic – Trepassey). The Placentia Health Centre/Lion’s Manor is operated directly by Eastern Health. The asset summary prepared during this review describes the condition of the infrastructure and provides a description of the specific deficiencies at each worksite. These are based on the mechanical, electrical, architectural, civil and functional assessments and are assigned a priority based on the level of urgency. It is recommended that the correction of these deficiencies occur over the next five years and this will cost approximately $800,000. During the biomedical equipment review, it was noted that the general X-ray equipment at the Abernathy Clinic in Trepassey is over 25 years old; parts are no longer available to repair this equipment should it become defective. The physiological patient monitoring system at the Placentia Health Centre is approximately 12 years old and is beyond its useful life. The cost to replace these pieces of equipment is approximately $280,000.

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