Central New Hampshire Health Partnership Community Health Needs Assessment 2011

PARTNERS Communities for Alcohol and Drug-Free Youth Community Action Program, Belknap-Merrimack Counties

Genesis Behavioral Health Mid-State Health Center Newfound Area Nursing Association

Pemi-Baker Community Health Plymouth Pediatrics and Adolescent Medicine

Plymouth Regional Clinic Speare Memorial Hospital

www.cnhhp.org

With technical assistance provided by Arielle Slam and Jonathan Stewart

NH Community Health Institute

Community Health Institute 1

Central NH Health Partnership Community Health Needs Assessment 2011

Central NH Health Partnership Service Area





Table of Contents

Executive Summary…………………………………………………………………………………1

Section A: Secondary Data Collection……………………………………………………15

Section B: Community Survey Summary & Analysis ……………………………37

Section C: Conversations with the Community ……………………………………51

Appendix I: Community Survey Results

Appendix II: Parent Focus Group Notes

Appendix III: Service Providers Focus Group Notes

Appendix IV: Faith Leaders Focus Group Notes

Appendix V: Focus Group Facilitator Script

Appendix VI: Community Leader Interview Script

Appendix VII: Sample Community Survey

Appendix VIII: Towns By Geography





Executive Summary

The 2011 Community Health Needs Assessment report is the most recent effort by the Central New

Hampshire Health Partnership to provide residents of the Greater Plymouth and Newfound region

with a comprehensive summary of the health of the area’s population. The specific aim of this

report is to:

Describe the current health status of the Greater Plymouth and Newfound population;

Summarize potential risks to the population’s future health;

Identify community health needs, priorities and aspirations from the perspective of area residents; and

Provide information to support collaboration among individuals, communities and the health care delivery and public health systems to assure the future health of the region’s population.

Overall, New Hampshire is a healthy state. In 2010, New Hampshire was ranked as the third

healthiest state in the nation and is consistently among the top 10 healthiest states according to a

commonly cited source of annual state health rankings.1 The Greater Plymouth and Newfound

region is similar to the State overall on many measures of health and well-being. Information from

community conversations and surveys included in this report further confirm that area residents

enjoy a high quality of life marked by appreciation of the natural environment, low rates of crime,

and a strong sense of community.

However, information included in this report also indicates that there remains work to be done to

meet the region’s potential for assuring the health and well-being of all area residents. Although

most residents are healthy and live relatively comfortable lives, the current health and well-being of

some area residents is not as good as it could be. Some residents are disabled by chronic disease,

some have limited or no access to routine health care through health insurance, some live in poverty,

and some die prematurely from preventable conditions. Additionally, many residents engage in

unhealthy life-style behaviors, behaviors that can be linked to chronic diseases, injury and even death

in the future.

Broad Definition of Health and a Model of Health Determinants

The definition of health used to frame this report was proposed by the Institute of Medicine2. In this

definition, health is defined as “a state of well-being and the capacity to function in the face of

changing circumstances.” This definition of health implies that “health” is the outcome of a mix of

many factors that interact at the individual, community, and societal level. Also, “health”

encompasses both the concept of “well-being” (health defined by the individual) as well as the

concept of “absence of illness and disease” (health defined by the medical system).



One model for visualizing how a community or society may act on this definition of health is the

Field Model of Health and Well-Being.3 As depicted by the illustration below, the domains of Health

and Well-Being are impacted by a number of inter-related factors. These include individual choices

and behaviors, as well as actions through the health care delivery system to promote health and

prevent disease and injury. At a broader societal level however, each of these are in turn influenced

by factors such as education and income levels, the physical and social conditions in which people

live including resources and policies that promote health, as well as social norms that influence

healthy lifestyles. The potential for interactions between these domains suggests a role for everyone,

from the individual, to the family, to the organizational and community levels, in producing

improved health and well-being for all residents of the Greater Plymouth and Newfound region of

New Hampshire.



Primary Sources of Data and Methods

The Central New Hampshire Health Partnership (CNHHP) used three primary methods for

gathering information on community health needs. Quantitative data were used to summarize

aspects of health and well-being for the population. Sources of data included the New Hampshire

Behavioral Risk Factor Surveillance System (BRFSS), the New Hampshire Youth Risk Behavior

Surveillance System (YRBSS), NH Vital Records Administration and NH Hospital Discharge Data.

Statistics were also collected from national sources, including the United States Census and the

American Community Survey.

A community needs survey was also distributed throughout the CNHHP service area from March

through June 2011. Survey respondents were asked to consider a number of health-related issues,

health care and community health needs, and were provided an opportunity to comment on what

they would do to make their community a healthier place. The survey was distributed using online

links and email blasts, display stands, asking front desk staff to prompt visitors to complete the

survey, and asking people to complete the survey outside of the Bristol Shop & Save. A total of 600

completed surveys were returned; representing about 2.2% of the entire adult population in the

service area.

Finally, a series of community conversations were held to provide richness and nuance and to

validate the quantitative data collected through secondary sources and the community survey. These

conversations included 22 community leader interviews and 3 focus groups. Community leaders

were defined as residents of the service area that also play key roles in health care or social service

delivery, or work in sectors that impact the community’s risk and resiliency factors. Focus groups

were conducted with a group of human service providers, parents participating in a parent education

group, and a group of faith community leaders.

Key Findings and Observations

1. Growing and Aging Population : The total population of the 21 towns comprising the

Greater Plymouth and Newfound region has grown by nearly 15% in the past 10 years to over

35,000 people. This rate of growth is higher than the statewide population growth of 6.5% over the

same time period. Most of the increase in population has occurred among residents who are 50 years

of age and older (net increase of 4,543 residents), while the total number of residents under 50 has

declined slightly (net decrease of 82 residents). This trend has significant implications for the

demand and capacity for health and human services to serve a growing and aging population in the

region.



2. Income and Insurance: As illustrated by the Field Model of Health and Well-Being,

prosperity can directly influence well-being, as well as the social and physical environmental

determinants of health. While New Hampshire is a relatively prosperous state overall, the median

household income in the Greater Plymouth and Newfound region lags behind the State median by

24%. As also indicated by the table below, about 11% of service area residents live in poverty with

household incomes less than 100% of the federal poverty level (FPL) and nearly 30% of service area

residents are considered low-income (< 200% of the FPL) compared with 20% of the state’s

residents overall.

Indicator CNHHP Service Area NH Overall

Population below federal poverty level (FPL) 10.6% 7.7%

Population below 200% of FPL 29.7% 20.0%

Median Household Income (2009) $46,218 $60,734

No health insurance 18.3% 10.8%

Income and employment influence the availability and affordability of health insurance. The rate of

uninsurance is also significantly higher in the region than for the state overall. A common theme

raised in the community conversations was that there are disparities in the region where people with

health insurance have sufficient access to high quality health services, while those without insurance

and with limited means struggle to achieve the same level of access and an associated level of health

and well-being. In the community survey, “Job Opportunities” was the number one characteristic

selected by respondents (56%) that should be focused on to support community health

improvement.

3. Access to Services: All 21 of the towns in the region are included in areas designated by the

federal government as Health Professional Shortage areas or Medically Underserved Populations. In

spite of this level of designation, nearly 90% of adults in the region have indicated that they do have

a regular primary care provider. However,

17% of the area’s adults also noted they

were unable to see a doctor when they

needed to because of cost compared with

only 11% of adults statewide who

reported this circumstance.

Respondents to the community survey

were also asked whether, in the past year,

they or someone in their family had

difficulty getting the services they needed.



About 44% of respondents selected “yes”, they had experienced difficulty accessing services. When

asked to specify further, the top 3 services with access difficulties reported by survey respondents

were as follows:

1. Dental care for adults 23.5% of all survey respondents 2. Primary health care 18.0% 3. Mental health 10.5%

Respondents reporting difficulty accessing services were also asked why it was difficult to access the services they needed. The top reasons cited were as follows:

1. Could not afford to pay 24.7% of all survey respondents 2. Had no health insurance 21.8% 3. Service I needed was not available 13.0%

4. Availability of Dental Care: As noted above, dental care for adults was cited most

frequently by community survey respondents as the service type for which they had experienced

difficulty getting the services they needed. About 6% of respondents also reported difficulty

accessing dental care for children. When asked to identify the “most pressing health issue” in the

community, about 50% of respondents selected “access to dental health care”; exceeding the next

highest rated issue - “access to enough health insurance” (39%) – by a substantial margin. The

limited availability of dental care was also a common theme in the community conversations and it

was noted in particular that there are currently no dentists located in the Newfound area. About

25% of adults in the Greater Plymouth region (not including the Newfound area) reported on the

statewide Behavioral Risk Factor Survey that they had not had dental visit in the past year; a rate

similar to the statewide rate.

5. Transportation: The lack of transportation in the region was also a common theme of the

community health needs assessment. As implied by the Field Model of Health and Well-Being,

residents with limited transportation options may also experience difficulty in accessing services and

participating in aspects of community life that contribute to individual and family health and well-

being. In our community survey, about 51% of respondents identified “public transportation” as a

service or resource that should be focused on for improvement to support a healthy community;

second only to improved job opportunities (56% of respondents). Similarly, when asked in an open-

ended question to identify the most difficult aspect of living in their community, the top difficulty

mentioned (18% of all respondents) was the lack of transportation including lack of public

transportation. Related issues of long

travel distances to services and

activities, as well as the associated costs

of transportation were also cited by

13% of respondents as the most

difficult aspect of living in the Greater

Plymouth and Newfound region.



6. Chronic Disease: In the Greater Plymouth region, 7.1% of all hospital discharges are for

chronic conditions that could be amenable to primary care such as diabetes and asthma. This rate is

statistically different and higher than the overall state rate (6.4% of hospital discharges). The

percentage of adults in the Greater Plymouth public health network service area who have ever been

told they have diabetes (9.4%) is slightly higher, but statistically similar to the state (7.2%) and

national percentages (8.4%). However, the burden of morbidity and mortality from diabetes is also

high in the service area. Compared with a national rate of 25.1 deaths per 100,000 people with

diabetes as an underlying cause, over 58 per 100,000 service area residents die with diabetes listed as

an underlying cause.

Similarly, rates of adult asthma are slightly higher, although not statistically different, in the Greater

Plymouth public health region compared to the state with nearly 12% of adults reporting a current

asthma diagnosis. It is important to also note that, according to the 2011 New Hampshire State

Health Profile, NH has among the highest rates of asthma in the nation with 10.2% of adults who

currently have asthma. As the state report notes, “Among the possible reasons for poor asthma

control are inadequate insurance coverage, including coverage for drugs, limited access to primary

care providers…” These are characteristics that describe the Greater Plymouth and Newfound

region as previously noted. Further evidence of the burden of asthma in the region is the relatively

high rate of asthma-related hospital discharges (99.7 discharges per 100,000 population compared

with a statewide rate of 80.0).

7. Behavioral Health and Substance Abuse: While access to dental care was identified

in the community survey as the most pressing health issue in the community, respondents also

frequently selected several factors associated with behavioral health including alcohol & drug use

(38% of survey respondents), access to mental health care (34%), youth alcohol & drug use (34%)

and mental illness (34%). Community members and leaders similarly described limitations in the

capacity of existing mental health and substance abuse treatment services and suggested a need for

additional mental health services such as psychiatrists, licensed alcohol and drug counselors,

emergency mental and substance use treatment services, and outpatient mental and addiction

services.

As displayed by the following table, inpatient and emergency department discharges for mental

health and substance abuse-related conditions are similar or lower than for the state overall. This

suggests that the perceived problems in the region regarding the prevalence of mental health and

substance abuse conditions and insufficient service capacity to address these issues are equally severe

across the state.



Indicator Greater Plymouth

Region NH Overall

Statistical Significance

Mental Health Condition Inpatient Discharges

per 100,000 People; age adjusted 376.0 484.6 Lower

Substance Abuse-Related Mental Health

Condition Inpatient Discharges per 100,000

People; age adjusted

427.7 438.2 Similar

Substance Abuse-Related Emergency

Department Visits per 100,000 People; age

adjusted

543.4 683.1 Lower

Mental Health Condition Emergency

Department Discharges per 100,000 People;

age adjusted

1252.9 1368.7 Lower

8. Healthy Eating and Active Living: Similar to diabetes, changing lifestyles have spurred

a nationwide increase in the number of overweight and obese adults. In the Greater Plymouth Public

Health Region, about 58% of adults are overweight or obese. This rate is similar to the statewide rate

of 63% of adults who are overweight or obese. While the community conversations found a

perceived lack of indoor exercise facilities in the area, it is interesting to note that area residents

exceed the percentage of adults statewide who regularly engage in moderate or vigorous physical

activity (65% region; 54% state).

Lack of good nutrition and nutrition education was the other major factor identified by community

leaders as a cause for the increasing overweight and obese population and was identified as a

pressing health issue by 35% of the community survey respondents. Additionally, a fitness/exercise

program was the most commonly selected type of service or program that they would use if more

available in the community (49% of respondents). The community survey also asked residents the

following question: “If you could change any one thing that you believe would contribute to better

health in your community, what would you change?” This question prompted a range of opinions

and thoughtful suggestions, but the most common theme (11% of respondents) can be categorized

as “Healthier Eating, Active Living”. This category included a variety of suggestions for community

health improvement

through a focus on

improving food choices,

including food served in

schools, and increasing

community resources to

promote indoor and

outdoor exercise.



It is the hope of the Central New Hampshire Health Partnership that the information contained in

this report will assist residents, area organizations, community groups, and municipalities to better

understand the community health needs in our region and to identify ways we can work together to

address some of these needs. All of us can participate in activities that benefit and strengthen our

community. Agencies may use the information in this report to prioritize available resources.

Community members may join with others to develop strategies and actions for addressing

significant needs, or as individuals we may choose to help neighbors by volunteering time and

expertise to help meet an identified need. Thank you to everyone who participated in this

assessment as well as to those who will work toward improvement of our community’s health and

well-being.



Section A Secondary Data Collection



Secondary Data Collection & Analysis

Methodology: Quantitative data were used to summarize aspects of health and well-being for the

population. The data were collected from national sources, including the US Census (2000 & 2010)

and the American Community Survey (2005-2009 5 year estimates). Data for this report was also

drawn from state sources including the New Hampshire Behavioral Risk Factor Surveillance System

(BRFSS), the New Hampshire Youth Risk Behavior Surveillance System (YRBSS), NH Vital Records

Administration and NH Hospital Discharge Data. Additional, state and local publications are

referenced.

Where available, data specific to the Central NH Health Partnership (CNHHP) service area are

provided. Towns included in the service area are: Alexandria, Ashland, Bridgewater, Bristol,

Campton, Danbury, Dorchester, Ellsworth, Grafton, Groton, Hebron, Holderness, Lincoln, New

Hampton, Orange, Plymouth, Rumney, Thornton, Warren, Waterville Valley, Wentworth, and

Woodstock. For indicators that did not have town level data, information for the next closet

geographic area was used, such as for the Greater Plymouth Public Health Region or Grafton County

overall.. To see population and towns by service area, public health region, and county see Appendix

VIII.

Some terminology used in this assessment includes the following. Prevalence is defined as the total

number of cases of a disease or risk factor in the population at a given point in time. Incidence

describes the number of new cases or events over a certain period of time, such as the annual

mortality rate. Mortality is used to describe death overall or as a result of a certain type of disease or

injury. The data may be presented as a crude count, but is most commonly shared as a rate or

percentage of the population. A rate is typically expressed as the number of events per 1,000, 10,000

or 100,000 people. Some rates are age-adjusted, which allows for comparison between populations

with different age distributions.

The researchers are thankful to the New Hampshire Department of Health and Human Services,

Office of Health Statistics and Data Management and NH HealthWRQS for their data and technical

assistance to this project.



Demographics: The service area is comprised of 21 towns of varying populations and

characteristics, ranging from the most densely and largely populated town of Plymouth (pop. 6990) to

Ellsworth with a population of 83. Figure 1 shows the population for each town in the service area by

age group. Ninety-nine percent of service area residents are of one race, 97.7% of those being white

while Asians make up the next highest single race group at 0.82%.4 Gender distribution is nearly

equal with 49% female and 51% male 5

Figure 1. CNHHP Service Area 2010 Population By Town

Towns

Total Pop

Under 5 years

5 to 19 years

20 to 24 years

25 to 34 years

35 to 49 years

50 to 64 years

65 to 74

years

75 and

older

Median age

(years)

Alexandria 1613 4.6% 17.7% 5.4% 9.7% 22.9% 25.9% 9.0% 4.8% 44.6

Ashland 2076 5.6% 14.0% 7.9% 13.1% 20.0% 22.6% 8.9% 7.9% 43.1

Bridgewater 1083 4.8% 14.1% 3.8% 7.3% 21.5% 26.2% 13.1% 9.1% 49.2

Bristol 3054 6.1% 17.4% 5.1% 11.1% 20.6% 24.2% 9.4% 6.1% 43.5

Campton 3333 4.8% 17.4% 4.9% 11.2% 21.7% 25.7% 8.9% 5.5% 44.1

Danbury 1164 4.6% 18.0% 3.6% 11.6% 21.6% 27.1% 8.2% 5.2% 44

Dorchester 355 2.3% 16.6% 3.9% 8.5% 21.7% 33.5% 7.0% 6.5% 49

Ellsworth 83 3.6% 15.7% 1.2% 9.6% 19.3% 22.9% 24.1% 3.6% 50.5

Grafton 1340 4.7% 15.5% 4.9% 9.9% 23.3% 27.1% 9.4% 5.1% 45.6

Groton 593 4.7% 14.0% 3.0% 9.4% 21.2% 28.3% 12.0% 7.3% 48.5

Hebron 602 3.7% 14.1% 2.7% 7.5% 14.0% 30.2% 15.9% 12.0% 55.1

Holderness 2108 3.7% 18.0% 6.3% 7.4% 19.9% 26.3% 10.9% 7.5% 46.9

Lincoln 1662 4.0% 16.1% 5.4% 8.9% 18.1% 27.1% 12.0% 8.4% 48.5

New Hampton

2165 5.9% 18.7% 3.2% 11.0% 22.7% 23.0% 9.0% 6.5% 42.4

Orange 331 4.2% 21.1% 4.5% 7.3% 25.7% 23.6% 9.4% 4.2% 42.9

Plymouth 6990 2.8% 28.0% 31.7% 6.6% 10.8% 12.2% 4.2% 3.8% 21.7

Rumney 1480 4.3% 19.1% 4.9% 8.8% 19.0% 26.6% 8.7% 8.6% 45.9

Thornton 2490 4.9% 15.5% 4.4% 9.8% 24.2% 27.0% 9.1% 5.1% 45.5

Waterville Valley

247 0.4% 17.4% 3.6% 2.8% 14.2% 34.8% 21.5% 5.3% 55.3

Wentworth 911 4.9% 14.9% 5.5% 10.8% 19.2% 24.8% 13.3% 6.6% 47.3

Woodstock 1374 4.1% 17.7% 5.3% 10.5% 22.8% 23.1% 10.3% 6.1% 44.2

CNHHP Total

35054 4.4% 19.0% 10.3% 9.3% 19.1% 23.0% 8.9% 6.0%

US Census, 2010



The total population of the service area has grown by nearly 15% in the past 10 years, with 7% of

that growth occurring in the last three years. This is higher than the statewide population growth

since 2000 of 6.5%. 6 7Older adults account for the largest proportion of this increase with nearly all

of the growth among residents 50 years and older. The only other age group to show positive

growth is 20-24, which may be representative of growth in the student body at Plymouth State

University.

Figure 2. CNHHP Service Area Population Growth by Age

Ages 2000

Population

2010

Population

% of Total

in 2010

Growth

2000-2010

Under 5 years 1545 1535 4.38% -0.65%

5 to 19 years 6913 6667 19.02% -3.56%

20 to 24 years 2740 3601 10.27% 31.42%

25 to 34 years 3437 3273 9.34% -4.77%

35 to 49 years 7217 6694 19.10% -7.25%

50 to 64 years 4967 8067 23.01% 62.41%

65 to 74 years 2182 3104 8.85% 42.25%

75 and older 1592 2113 6.03% 32.73%

Service Area Total 28107 35054 14.58%

NH Total 1,235,786 1,316,470 6.5%

US Census Data, 2000 & 2010

Socioeconomic Indicators

Poverty: Over 10% of service area residents live in poverty with household incomes less than

100% of the federal poverty level (FPL). Nearly 30% of service area residents, as opposed to 20% of

New Hampshire residents overall, are considered low-income (< 200% of the FPL).

Income & Insurance: High unemployment in the service and retail sector, seasonal tourism and

other small business employers, leave many individuals and families completely uninsured. In 2010,

state unemployment was at 6.1% and Grafton County unemployment was at 4.9%.8 The median

household income in the service area is only about 76% of that of the State overall. Only two towns

in the region (Waterville Valley and Ellsworth) exceed the statewide median household income, and

several towns including Ashland, Bristol and Lincoln have a median household incomes of about

60% or less of that of New Hampshire overall.9



Figure 3 shows that the estimated proportion of the service area without health insurance (18.3%) is

significantly higher than the overall state rate and is also higher than the national rate (15.5%

uninsured, US Census Bureau, 2010).

Figure 3. Service Area Economic Indicators

Indicator CNHHP Service

Area NH Overall

Population below federal poverty leveli 10.6% 7.7%

Population below 200% of federal poverty leveli 29.7% 20%

Median Household Incomei $46,218 $60,734

No health insurance 18.3%ii 10.8%iii

i. American Community Survey, 2005-2009

ii. Estimate based on total population (Census 2010) under 200% poverty in service area (ACS 05-09) less

total Medicaid population in service area(NH Medicaid Annual Report, FY10)

iii. 2011 NH Regional Health Profiles, NH DHHS, Division of Public Health Services, 2008-2009 data

Access to Care: The service area is comprised principally of communities with

underserved/shortage area designations reflecting limited access to primary care professionals and

related health services. All 21 of the service area towns are designated as Health Professional

Shortage areas, Medically Underserved Populations, or both. In the service area:

Nineteen of the 21 service area towns are federally designated Medically Underserved

Populations (MUPs).

Seventeen of the towns are designated as Health Professional Shortage Areas (HPSAs)

Eighteen of the towns are included in a mental health HPSA

Twelve of the towns are included in a low-income Dental HPSA

As a critical access hospital, Speare Memorial Hospital serves the vast majority of residents from the

service area. Even residents from the Newfound area that may be geographically closer to hospitals

in Franklin/Laconia, receive the majority of their hospital care at Speare Memorial Hospital.10

Nearly 90% (89.7%) of adults in the public health region have indicated that they have a primary

care provider; however, 17% of the area’s adults noted they were unable to see a doctor when they

needed to because of the cost compared with only 11% statewide.11

Twenty-five percent of Grafton County adults report they did not have a dental health visit in the

past year and 74.8% reported having a dental visit in the past year. Nationally, 56.69% of adults go

without a dental visit in a year.12



Figure 4. Access to Care13


Public Health Region New Hampshire

Have primary care provider, percent of

all adults 89.7 88.9

No health insurance, percent of all

adults 18.3 10.8

Unable to see a doctor when needed

due to cost, percent of all adults 17.1 10.9

Did not have a dental health visit in

the past year, percent of all adults 25.2 24

Preventable Hospitalizations

Acute ambulatory care sensitive

condition hospital discharges, percent

of all discharges

6.9 7.2

Chronic ambulatory care sensitive

condition hospitals discharges, percent

of all discharges

7.1 6.4

Substance abuse-related emergency

hospital discharges 35.9 32.1

Preventive Screenings

Mammogram in past two years,

percent of all women age 40 and older 71.4 81.0

Colonoscopy or sigmoidoscopy in past

5 years, percent of adults age 50 and

older

52.4 58.2

Pap test in past 3 years, percent of

women age 18 and older 84.1 87.1

Cholesterol tested past 5 years,

percent of adults 78.2 81.9

Only indicators in red are statistically significant differences from the state rate/percentage.



19% 3%

6%

72%

Figure 5. Household Composition in Service Area, 05-09

Married-couple family with childrenunder 18 years present

Male householder with no wife presentand children present under 18 yrs

Female householder with no husbandpresent and children present under 18years

Households with no people under 18years

Data Source: 2005-2009 American Community Survey, 5 year estimates

Education: An individual’s educational attainment is positively correlated with better health

outcomes and therefore is a relevant indicator of a population’s health status. Across age groups,

service area residents lag behind the state in achievement of undergraduate and advanced degrees.14

While newer generations of residents in the services area are reaching higher levels of educational

attainment than older residents, the majority of the adult population in the area does not have a

college degree.

Fifty-eight percent (58%) of adults 25-34 in the service area have had education beyond high

school or the GED versus 66% statewide.

Among 25-34 year olds, 36% of males and 33% of females hold high school degrees or

GEDs as their highest level of academic achievement.

Females continue to not only bridge but to exceed the gap between sexes in educational

achievement. In fact, 33% of females 25-34 years old have Bachelor’s degree, while only

21.29% of their male counterparts have achieved the same level..15

Family structure: Perhaps indicative of the large population

of older adults in the service area, the vast majority of households

(72%) have no children living with them (figure 5). The ratio of

married w/children households, single family households, and

childless households is comparable statewide and nationally

(figure 6). Among households with children (regardless of

paternity), 66% (2314) of the households include a married

couple. 16

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0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%

Married-couplefamily with children

under 18 yearspresent

Male householderwith no wife presentand children present

under 18 yrs

Female householderwith no husband

present and childrenpresent under 18

years

Households with nopeople under 18

years

Figure 6. Household Structure Comparison

United States (%)

New Hampshire (%)

Service Area (%)

Data Source: 05-09 ACS

Death Indicators

Premature death, or death under the age of 65, is high in the area with a rate of 218.3 premature

deaths per 100,000.17 This is of particular concern (and statistically significant) when compared with

the State rate of 180.1. Premature mortality is highest among 55-64 year olds in the region (926.3 in

the service area versus 727.7 in the state).18 Death from chronic lower respiratory disease

(emphysema & bronchitis), a disease primarily caused by cigarette smoking, is particularly high

among this age group in the region (85.7 in Greater Plymouth Public Health Region versus 40.6

statewide). However, the total number of events is small, which negates any statistical significance.19

As the 2011 State Health Profile reports, eight of the top 10 causes of death in the state and the

service area are related to individuals’ modifiable lifestyle and behavior.20

Cancer is a leading cause of death in the service area (192.5) and statewide (193.1), although the rate

is still below the national rate of 196.1.21 When adjusted for age distribution across geographies, the

rates again are comparable with the public health region at 173.1 and the state at185, respectively.22

Total cancer incidence rates (500 per 100,000) are also comparable to the state (495.2) and the

nation (458.7).23 Again, when age-adjusted cancer rates remain comparable between the region and

the state.24

The only leading cause of death in the area to exceed state rates is accidents, specifically among 45-

54 year olds. Regionally, the rate of unintentional injury deaths for this age group is 64.4 while

statewide it is only 31.7.25

Suicide deaths in the area match the state rate: at 11.5 per 100,000.26



Figure 7. Overall Leading Causes of Death (rate per 100,000)

Leading Causes Service Area NH State

Cancer 192.5 193.1

Heart Disease 183.6 189.3

Chronic lower respiratory diseases

(including emphysema & bronchitis) 39.8 46.3

Accidents 37.6 36.7

Stroke 23.2 37.2

Alzheimer’s Disease 19.9 29.4

Influenza and pneumonia 12.2 17.3

Suicide 11.1 11.8

Diabetes 11.1 22.3

Chronic liver disease and cirrhosis 11.1 x

NH Division of Vital Records Administration Death Certificate Data, 05-07

missing towns: Groton, Hebron, Lincoln, Waterville Valley, Wentworth

Prenatal

Infants born with a low birth weight are at a higher risk of infant

mortality and of long-term health issues than babies born at a normal

weight.27 At less than 5%, the proportion of low birth weight infants in

the region is slightly lower, although statistically similar to the state and

nation (4.8% CNHHP, 6.5% NH, 6% US).28

Women who smoke during pregnancy are more likely to give birth

prematurely, have complications in birth, and give birth to a low-birth

weight baby.29 Therefore, it is of concern that cigarette use during

pregnancy is higher in the service area (18.2%) than nationally (10-12%),

although the service area rate is similar to the state rate (16.4%) for this

indicator.30 31

NH has one of the lowest teen birth rates in the country. As the 2011 NH State Health Profile

reports, teen birth rates have steadily declined since 1990 when the rate was 30 births per 1,000

females age 15-19.32 The most recent statistic for the statewide teen birth rate is 18.4, while the rate



of births to teenagers in the service area is even lower at 14.7 per 1,000. This rate is approximately

one third of the national teen birth rate (42.5 births per 1,000 females age 15-19).33 34

The number of infants born to unmarried mothers (37.1%) is however a statistic that exceeds the

national rate of 28.6% for e the non-hispanic white population..

Of birth births from 2006-2008, 39.8% were to Medicaid/CHIP patients.35

Adequacy of prenatal care is an indicator often used to assess the level of access and quality of

prenatal services available in a community. At

20%, the service area has a slightly higher rate of

late entry into prenatal care compared to the

national average of 16% late entry. 36 37 Figure 8

uses the Prenatal Care Adequacy Index to

illustrate the level of prenatal care in the service

area. The index considers both the time of initial

entry to prenatal care and the number of prenatal

visits compared with standard professional

recommendations. Overall, about 83.5% of

women in the region received prenatal care

documented at the adequate or better level.

Child Health

The first years of life are considered the most important for cultivating the foundation for success

throughout the life span. For children to have the best health outcomes, they should have regular

access to high-quality health care including access to preventive health services such as immunizations

and screening tests. Additionally, supporting good personal health behaviors and monitoring

behaviors that could indicate the development of problems is important in building a healthy

foundation for a child’s development. 38

Lead Testing: Currently, most children in the region are not routinely tested for elevated blood

lead levels. Less than half of children in the area (47.8%) are tested by the time they are 3 years old

compared to 93% of children 3 years and under tested nationally.39 Lead poisoning can have broad

effects on children including intellectual and behavioral deficits.40 In 2009, the service area reported

that 3.16% of children tested had elevated blood level counts, which despite being a very small

population count is significantly higher than the state percentage of 0.78%. 41

Elevated lead blood levels are typically seen in areas with older housing built before 1950. Older

housing stocks are frequently concentrated in urban centers. While Central NH is not devoid of older

PNC Adequacy Index % Service Area

Missing information 3.6%

Inadequate 9.6%

Intermediate 6.3%

Adequate 42.7%

Adequate Plus 37.8%

NH Department of State, Division of Vital Records

Administration, 2006-2008

Figure 8. Adequacy of Prenatal Care,

2006-2009



NH 2008-2009 Third Grade Healthy Smiles-Healthy Growth

Survey

infrastructure, the housing tends towards newer buildings with the average year of construction being

1976. The percentage of housing built before 1950 in the Central NH area is less than 1 in 4 (22%).42

Immunization: Relative to the state and the nation, the Greater Plymouth and Newfound region

is effective in ensuring that children are protected from vaccine preventable diseases. In Grafton

County only around 17% of children do not receive their recommended immunizations (4:3:1:3:3:1:4

series) versus 26.2% in NH and 34.3% nationally. 43 44

Oral Health: Poor oral health puts children at risk for infection and/or pain and missed school.45

One proven prevention method for

decreasing tooth decay is the application of

dental sealants.46 A 2009 NH survey showed

that Grafton & Carroll Counties were far

behind the statewide percentage of third

graders who had dental sealants (39.8 %

Grafton/Carroll County; 60.4% NH).47 Lack

of preventive dental care and treatment was

identified as the top health issue in the

community survey (see Section B) and

recognized by many community leaders as a

pressing health issue (see Section C). The 2009

report also shows that statewide dental decay

is significantly higher in schools where more

than half the children were at or below 185%

of poverty. This further supports the local

community’s observations that inaccessibility

of oral health care disproportionately affects impoverished populations.

Healthy Eating & Active Living: Increasing obesity and the associated medical problems is

an ongoing trend nationally, and a growing problem among children in the service area. Providing

opportunities for children to eat healthy and be physically active are essential to reversing the obesity

problem. As detailed in Section B, 11% of community survey respondents described factors

associated with healthier eating and active living as the most important area of emphasis for

improving health in the community.

Nearly 17% percent of third graders in Grafton and Carroll counties are considered overweight and

17.7% are obese. This is comparable to third graders statewide who are either overweight or obese

(33.4%).48 A 2003 NH study indicated that higher BMI levels are correlated with lower academic

performance and higher rates of absenteeism have been linked with childhood obesity.49

A NH study conducted in 2004 also showed the impact of narrowing opportunities for physical

education during the school day. The study showed a decrease from 88% proficiency to 47% in the

number of students able to complete a minimum fitness level test from the time of school entry to

Figure 9. Prevalence of Oral Health Indicators

Among Third Graders, 2008-2009

Variable Carroll &

Grafton County

New

Hampshire

Decay experience 46.7 43.9

Untreated decay 17.0 12.0

Dental sealants 39.8 60.4

Need treatment

(early & urgent) 16.7 12.0

Need urgent

treatment 2.5 1.0



the second year of school. The study showed a steady decrease as the student’s advanced in school

years.50 Fortunately, school age children appear to have more opportunities for daily physical activity

outside of the classroom. Statewide the percentage of children, age 6-17, who were physically active

for a total of at least 20 minutes per day in the past 7 days has increased from 25% in 2003 to 29% in

2007. Similarly, high schools students experienced a 4% increase in weekly level of physical activity.51

Missed School: As previously mentioned, educational achievement is a protective factor for good

health. Similarly, a child’s health status can directly affect his/her academic success. Among 6-17 year

olds in the service area, 13.4% of them missed between 6 and 10 days of school due to illness or

injury in the past year. This is compared to 12.3% nationally among the same age group.52

Also of note, school absenteeism is also associated with involvement in risky behavior, including

substance use and risky sexual behavior.53

Substance Use: Assessment of teen health risks and behaviors has been conducted using the

Teen Assessment Project (TAP) Survey in the Pemi-Baker Region since 1999 and in the Newfound

Region since 2003. Figures 10 & 11 illustrate school trends for use of alcohol, tobacco or marijuana

in the 30 days prior to the survey administration. The results reveal some recent improvements on

these measures in the Newfound Region and some reversal of significant gains made in the Pemi-

Baker region in previous years. The results demonstrate that a majority of teens are not engaging in

behaviors potentially detrimental to their health, but that a significant proportion of teens do report

frequent use of alcohol, marijuana and tobacco.

Figure 10.



Figure 12 compares the 2009 regional results for 30 day substance use by high school age youth with

state and national results for these same measures (identical survey question wording). In general,

youth in the region tend to report similar rates of cigarette smoking compared with state and

national rates, and lower rates of recent alcohol use. NH and the service area tend to experience

higher rates of teen marijuana use when compared with the nation.

Figure 12. Comparison of Regional TAP Results with State & National YRBS Results (2009) For Substance Use in Past 30 Days (Percent of Respondents)

Cigarettes Alcohol Marijuana

Pemi: Males 22.6 35.4 28.8

Pemi: Females 18.0 39.4 23.3

Pemi: Total 20.1 37.4 25.8

Newfound: Males 20.0 33.0 33.7

Newfound: Females 16.2 32.0 18.6

Newfound: Total 18.1 32.9 26.4

NH:Males 21.6 39.2 28.1

NH: Females 20.0 39.4 22.9

NH: Total 20.8 39.3 25.6

US: Males 19.8 40.8 23.4

US: Females 19.1 42.9 17.9

US: Total 19.5 41.8 20.8

Figure 11.



Despite the fact that a large majority of youth are not engaging in frequent high risk health

behaviors, including substance use, there remains a subgroup of youth who are. One of the most

compelling findings from the TAP survey studies is the association between one risky health

behavior and other risky behaviors. Figures 13 and 14 display the association between binge drinking

(5 or more drinks over a few hours; ‘drinking to get drunk’) and other high risk behaviors. As the

charts display, youth who report binge drinking in the past 30 days are significantly more likely to

also report other high risk health behaviors.

Figure 13.

Figure 14.



There is significant published evidence that substance use and other health risk behaviors put youth

at risk for delayed emotional and intellectual growth; developing problems with schools, friends and

families; incurring ill health and reduced longevity; accidents; suicide; and unwanted pregnancies.

Given the risks accompanying these behaviors, it is incumbent upon the community to attempt an

understanding of what can be done to minimize the likelihood of these youth choices. One possible

action is to increase the protective factors for youth. Protective factors “protect” or lessen the

likelihood that youth will participate in behaviors that have negative health and social outcomes.

These protective factors exist at each level of an ecological model of health promotion including

individual and peers, family, school, and community.

ADULT HEALTH

Diabetes: Diabetes is a disorder causing high blood glucose levels that impair the circulatory

system putting a person at risk for many serious health conditions including: heart disease, blindness,

nerve, and kidney damage. Changing lifestyles including eating habits and levels of physical activity

have contributed to an epidemic of diabetes across the United States. The percent of adults in the

Greater Plymouth public health network service area who have ever been told they have diabetes

(9.4%) is slightly higher, but statistically similar to the state (7.2%) and national percentages (8.4%).54

When looking at diabetes rates across different socioeconomic groups, rates are twice as high

statewide for residents with less than a high school education that those with a college degree. Even

more dramatic variation is present between income levels; those earning less than $15,000 a year have

diabetes rates three times higher than those earning $75,000 a year or more.55 The burden of

morbidity and mortality from diabetes is also high in the service area. Compared with a national rate

of 25.1 deaths per 100,000 people with diabetes as an underlying cause, over 58 per 100,000 service

area residents die with diabetes listed as an underlying cause.56 Additionally, the service area has a

relatively high rate of diabetes related amputations (34.6 per 100,000) compared with the state rate

(19.9), although it is similar to the national rate (37.5 per 100,000). 57

Figure 15. Diabetes

Indicator Service Area NH State US

Diabetes prevalence, Percent of all adults 9.4% 7.2% 8.4%

Diabetes related lower extremity

amputation inpatient discharges, Rate per 100,000 34.6 19.9 37.5

Diabetes as underlying cause of death, Rate per

100,000 58.1 73.1 25.1

NH DHHS Hospital Discharge Data Collection System, 03-07

CDC National Diabetes Surveillance System, retrieved 2010

NH Division of Vital Records Administration Death Certificate Data, 05-07

* NH Data missing towns: Lincoln, Waterville Valley, Wentworth, Orange, Woodstock



Healthy Eating & Active Living: Similar to diabetes, changing lifestyles have spurred a

nationwide increase in the number of overweight and obese adults. In the Greater Plymouth Public

Health Region, 33.6% of adults are overweight and 24.1% are obese, which is comparable to the

statewide rates of 37.2% overweight adults and 25.8% obese adults, and similar to national rates.58

Daily fruit and vegetable consumption in the area matches the statewide rate, with around 26% of

adults reporting that they consume fruits and vegetables five or more times per day. 59

Despite the perceived lack of indoor exercise facilities in the area (see infrastructure needs addressed

in Section B & C), residents exceed the percentage of adults statewide (53.5% NH) who engage in

moderate or vigorous physical activity (65% region).60

Figure 16. Healthy Eating & Active Living

Health Behaviors (Percent of Adults)

Greater Plymouth PHN

New Hampshire

Obese 24.1 25.8

Overweight 33.6 37.2

Fruits and vegetables five or more times per day 26.3 28.0

Moderate or vigorous physical activity 65.2 53.5

Data Source: 2011 NH Regional Health Profiles

Cardiovascular Health: As detailed under leading causes of death, death from diseases of the heart

is the second killer in the service area. The service area faces a mortality rate of 183.6 from diseases of

the heart, though nationally the rate is 240.8.61 62 When considering both principal and secondary

diagnoses the rate of congestive heart failure in the area is 787.8 cases per 100,000 population. Still

higher, hypertension affects 2,475.5 persons per 100,000 service area residents when including

secondary diagnoses. Unfortunately comparable state and national benchmarks are not available.

When considering the confidence intervals, rates have remained mostly constant in the region from

1998-2007..63

Nearly 21% of adults in the public health region reported being diagnosed with high blood pressure,

compared to 27.6 % statewide.64 Also comparable between the region and the state are rates of being tested

for high cholesterol in the past 5 years (78.2% in Greater Plymouth PHN and 81.9% statewide).65



Figure 18. Cardiovascular Rates in Service Area

Hospital

Admissions by

Diagnosis

1998-2002

Service Area Rate Per

100,000 By Primary

Diagnosis i

2003-2007

Service Area Rate Per

100,000 by Primary

Diagnosis i

2010

US Rate per

100,000 i i

Congestive Heart

Failure 222.6 212.9 502.8

Hypertension 25.8 35.1 50.2

i . 2003-2007 NH Health Statistics & Data Management

ii . HRSA, Bureau of Primary Health Care, 2010

Adult Asthma: The 2011 NH State Health Profile reports that NH has among the highest rates

of asthma in the nation with 10.2% of adults who currently have asthma. Rates of adult asthma are

slightly higher, although not statistically different, in the Greater Plymouth public health region

compared to the state with nearly 12% of adults reporting a current asthma diagnosis.66 As the state

report notes, “Among the possible reasons for poor asthma control are inadequate insurance

coverage, including coverage for drugs, limited access to primary care providers…” Considering the

high rate of uninsured residents in the service area, lack of access to services may be one driver of the

higher than average rates of asthma. Further evidencing resident’s lack of access to asthma care is the

high rate of asthma related emergency department visits. Compared to the state rate of 491.1 asthma

emergency department visits per 100,000 people, Grafton County’s rate is higher at 587.3.67

0

500

1,000

1,500

2,000

2,500

3,000

Angina pectoris Congestive heart failure Hypertension

Sta

nd

ard

ized

rate

per

100,0

00 p

op

ula

tio

n

Figure 17. Service Area Change in Cardiovascular Health 1998-2007

1998 to 2002 2003 to 2007

Between the 5-year spans of 1998 to 2002 and 2003 to 2007, the admission rate of angina pectoris was significantly lower during the latter 5-year period. Hypertension shows no statistically significant differences in the inpatient admission rates between the 2 periods. Congestive heart failure admission rates were significantly lower between 1998 and 2002.

NH DHHS, 2010



Figure 19. Adult Asthma


Public Health Region New Hampshire

Current Asthma, Percent Adults 11.8% 10.2%

Asthma Emergency Department

Visits Per 100,000 (all ages) 587.3 491.1

NH Hospital Discharge Data Collection, 2006 & 2011 Regional Health Profiles

Mental Health: Poor mental health can affect various aspects of an individual’s life including

ability to access care, be productive and engage in fulfilling relationships.68 In Grafton County, 36.3%

of adults reported that there were days in the past month when their mental health was not good.69

Additionally, the prevalence of adults in Grafton, Coos and Carroll Counties reporting having at least

one major depressive episode in the past year (8.43) exceeded the national average of 7.55.70 Suicide

rates for the service area (11.5 per 100,000) mirror the state (11.2) and US rates (11.0). 71

Substance Use: Long term heavy alcohol consumption increases an individual’s risk for many

health problems including heart disease and stroke, as well as mental health problems It may also

increase instances of homicides, suicides, domestic violence, and child abuse.72 The percentage of

adults who engage in heavy drinking and binge drinking in the public health region is near equal to

that of that state with regional percentages of 4.6% and 14.9%, respectively.73 Reported illicit drug use

in the past month is higher for Grafton, Carroll and Coos counties (11.5%) than the state (10.3%)

and US rates (8.2%).74 Regionally and statewide, inpatient discharges with a principal diagnosis of a

substance abuse related mental health disorder are 427.7 and 438.2 per 100,000 population,

respectively. Contrary to public perception noted in Section B & C, young adults in the area (15-24

year olds) have lower rates of substance abuse related mental health condition inpatient discharges

(268.2) compared to the state overall (390.6).75 Community perceptions and identified issues related

to emergency services for those with mental health and substance use problems are further

described in Sections B & C.

Among adults in the region, 18.2% are smokers while only 16.5% of adults throughout the state are

currently smoking.76 As noted earlier in the report, cigarette smoking is a major cause of chronic

lower respiratory disease, a leading cause of mortality in the service area.



Personal Safety: “Every 14 seconds, an adult in the United

States is treated in an emergency department for crash-related

injuries.”77 Ensuring that drivers and passengers are buckled up every

time they are in a car can reduce one of the leading causes of death by

45-60%.78 Seatbelt use among adults is dramatically lower in New

Hampshire and the service area than nationwide. While nationally

85% of passengers and drivers always wear seatbelts, only 65.6% of

adults in the state and 60.9% of adults in the region report always

wearing seatbelts.79 New Hampshire is currently the only state in the

nation that does not have a mandatory safety belt law. Mandatory laws, as well as primary seatbelt

enforcement laws, which permit an officer to pull cars over and issue tickets solely because drivers

and passengers are unbelted, are strongly correlated with increased seatbelt use.80

Figure 20. Health Behaviors

Health Behaviors (Percent of Adults) Greater Plymouth

Public Health Region New

Hampshire

Substance Use

Heavy drinking 4.6 6.0

Binge drinking 14.9 16.1

Any Illicit drug use in past month i 11.48 10.3

Current smoking 18.2 16.5

Personal Safety

Always use seatbelt 60.9 65.6

All sourced from following unless otherwise cited: NH Bureau of Public Health Statistics and Informatics, 2006-2009

i. National Survey on Drug Use & Health, 06-08 statistic for Grafton, Carroll, & Coos



Never 49%

Sometimes 31%

Often 9%

Always 11%

Figure 21. Reported Difficulty Traveling in Service Area

North Country Council-Transport Central, 2010

Environment

Transportation : A 2010 transit feasibility study of 19 towns in the 21 town service area

highlighted the necessity of access to

transportation for the relatively small

population dispersed over more than

750 square miles.81 Among transit

survey respondents, 20% reported

frequently or always having difficulty

traveling in and around the service

area. Additionally, medical services

were the second most frequently

cited reason for travel in and around

the area. The study also noted a need

for transportation to social service

providers, such as Head Start,

particularly in the Plymouth area.

In the CNHHP community health needs survey, about 51% of respondents identified “public

transportation” as a service or resource that should be focused on for improvement to support a

healthy community; second only to improved job opportunities (56% of respondents). Similarly,

when asked in an open-ended question to identify the most difficult aspect of living in their

community, the top difficulty mentioned (18% of all respondents) was the lack of transportation

including lack of public transportation

Housing: Where public housing is available in the area, residents are waiting a minimum of 8

months.82 Those stuck in this waiting period may become homeless. A January 2011 point in time

count of the homeless population in Grafton County found 68 individuals currently in shelter care

and 19 homeless individuals who were unsheltered. Among those unsheltered, 11 of the individuals

were part of a homeless family (total of 3 families). An additional 8 individuals were temporarily

residing with family or friends.83





Section B Community Survey

Summary & Analysis



Methodology: A 14 question community needs survey was distributed throughout the CNHHP service area from March through June 2011. The survey was distributed using online links, email blasts, display stands, asking front desk staff to prompt visitors to complete the survey, and asking people to complete the survey outside of the Bristol Shop & Save. A total of 600 completed surveys were returned; representing about 2.2% of the entire adult population in the service area (427 hardcopy surveys and 173 using the online survey collector.)

Survey respondents were asked to consider a number of health-related issues and were provided an opportunity to comment on what they would do to make their community a healthier place. With regard to the concept of community, respondents were instructed as follows: “Your community” can mean different things to different people. For the purpose of the survey, your community can be as big as the Greater Plymouth & Newfound area or as small as your town. Answer the survey questions by thinking about the area you see as “your community”. As an incentive to complete the survey, respondents were informed that $2 would be donated to a local charity by the Central NH Health Partnership for each local resident that completed the survey.

Respondent Demographics: Of the 600 community health needs surveys completed, at least one survey was received from every town in the Central NH Health Partnership service area. As displayed in figure 22 and 23, the survey corresponds geographically with the proportion of the service area population represented by each town.

Figure 22. Comparison of Survey Sample With Regional Population By Town

% of Total Service Area Population

% of Survey Respondents

Difference

Alexandria 4.6 5.1 0.5 Ashland 5.9 7.1 1.2 Bridgewater 3.1 3.6 0.5 Bristol 8.7 12.9 4.2 Campton 9.5 10.4 0.9 Danbury 3.3 1.3 -2.0 Dorchester 1.0 0.4 -0.6 Ellsworth 0.2 0.2 0.0 Grafton 3.8 0.5 -3.3 Groton 1.7 2.2 0.5 Hebron 1.7 2.2 0.5 Holderness 6.0 5.8 -0.2 Lincoln 4.7 1.5 -3.2 New Hampton 6.2 2.7 -3.5 Orange 0.9 0.2 -0.7 Plymouth 19.9 23.1 3.2 Rumney 4.2 5.6 1.4 Thornton 7.1 6.2 -0.9 Waterville Valley 0.7 0.5 -0.2 Wentworth 2.6 2.6 0.0 Woodstock 3.9 1.1 -2.8 Other 3.8 3.8 TOTAL 100 100



As displayed in figure 34, there is also good overall correspondence between the age breakdown of survey respondents and the survey sample. The population age 24 and under is slightly under-represented proportionally, however the next youngest age bracket (25-34) is where the most of the proportional difference is accounted for.

0

5

10

15

20

25

30

35

18-19 20 to 24 25 to 34 35 to 49 50 to 64 65 to 74 75+

Age in years

Age distribution of the Service Area and the Survey Sample

% of Service Area Population

% of Survey Sample

Figure 23.

Figure 24.



Survey respondents were also asked to indicate their household income bracket and about 86% of survey respondents did provide that information. Figure 25 displays the breakdown of household income by income bracket for the survey sample. The median value for this categorical question can be used to roughly approximate the median income for households represented in the survey. Using this technique, the median household income is estimated to be $42,180 which is similar to the median household income for the region of $46,218 as estimated by the US Census Bureau.

Figure 26 shows additional information describing the demographics of survey respondents. A significant majority of respondents are female (about 76%), have lived in the Greater Plymouth/Newfound region for about 21 years on average, and have a median household size of 3 people.

Figure 26. Additional Respondent Demographics

Gender Male 24.3% Female 75.7%

Mean Median Minimum Maximum Number of Years in the Region

20.9 years 18.0 years 1 month 86 years

Number of People in the Household

2.9 3 1 13

16.1%

19.6%

26.3%

18.1%

11.9%

8.0%

Figure 25. Household Income CNHHP Community Needs Survey Sample

Less than $10,000

$10,000- $25,000

$25,000- $49,000

$50,000- $74,000

$75,000- $100,000

More than $100,000



Most Pressing Health Issues: The survey asked respondents to indicate what they thought are the most pressing health issues in their community today. Respondents were instructed that they could select up to 5 different items and/or fill in an open-ended “other” category. The top 10 most pressing health issues reported by area residents are: 1. Access to dental health care 50.2% of respondents 2. Access to enough health insurance 39.2% 3. Alcohol & drug use 37.5% 4. Not enough exercise 35.9% 5. Poor nutrition/unhealthy food 34.7% 6. Access to mental health care 34.4% 7. Youth alcohol & drug use 34.1% 8. Mental illness 33.7% 9. Access to primary health care 32.4% 10. Smoking/tobacco use 25.3%

Access to specialty services was noted as a pressing health issue by 8.5% of respondents. Given the opportunity to specify which specialty services, the most common responses were: more local service options in general (not specific) (1.5%), mental health services (1.0%), and transportation (0.7%).

The complete ranking of “pressing health issues” is displayed by figure 27 and the complete set of tabulated and open-ended results are included in Appendix I.

Figure 27.



Most Pressing Community Safety Issues: The survey next asked respondents to indicate what they thought are the most pressing safety issues in their community today. Again respondents could select up to 5 items and also write in an issue not listed. The top 7 most pressing safety issues reported by area residents are: 1. People under the influence of alcohol or drugs 64.1% of respondents 2. Domestic violence or partner abuse 50.3% 3. Bullying/cyber-bullying 49.8% 4. Child abuse or neglect 49.0% 5. Being prepared for an emergency 25.4% 6. Youth crime 21.8% 7. Crime 21.3% The most common “Other” responses for most pressing safety issues are Driving/Traffic safety (1.5%) and ‘not enough activities for youth (0.5%).

The complete ranking of “pressing safety issues” is displayed by the chart below and the complete set of tabulated and open-ended responses are included in Appendix I.

Figure 28.



Services or Resources to Support a Healthy Community: The survey asked respondents to indicate what services or resources should be focused on for improvement to support a healthy community. Again respondents could select up to 5 items and also write in an issue not listed. The top 9 areas of focus to support a healthy community as reported by area residents are: 1. Job opportunities 55.8% of respondents 2. Public transportation 50.7% 3. Access to affordable housing 49.8% 4. Youth programs and support 36.1% 5. Access to affordable food 31.3% 6. Parenting support 28.9% 7. Support for older adults 26.7% 8. Job training 26.5% 9. Quality child care 25.2% The most common “Other” responses for services or resources to support a healthy community are: Access to affordable health care (1.3%), domestic violence education/support (1.2%), mental health support/resources (0.5%), and poverty reduction (0.5%).

The complete ranking of “services or resources for improvement to support a healthy community” is displayed in figure 29. The complete set of tabulated and open-ended responses is included in Appendix I.

Figure 29.



Access to Services: Survey respondents were asked whether, in the past year, they or someone in their family had difficulty getting the services they needed. About 44% of respondents selected “yes”, they had experienced difficulty accessing services. Respondents who selected “yes” were asked two follow-up questions. The first question asked which services they or their family have difficulty accessing. The top 5 services with access difficulties reported by survey respondents were as follows: 1. Dental care for adults 23.5% of all respondents 2. Primary health care 18.0% 3. Mental health 10.5% 4. Social/human service agencies 9.3% 5. Specialty Health Care 7.2% Please note that the percentages reported above and on the chart below are the proportion of all survey respondents (n=600); not just of the subset of respondents indicating access difficulties. It is reported in this manner to provide perspective on the proportion of the whole population reporting this experience.

With respect to “specialty health care”, respondents were provided the opportunity to specify a particular specialty or specialties. The most common responses with respect to difficulty accessing specialty health care are Orthopedics (0.5%), Diabetes (0.3%) and Dental (0.3%). “Other” services commonly mentioned with respect to access difficulty not included on the list are transportation (0.8%) and financial/eligibility assistance (0.7%).

Fig 30.

Figure 31.



Respondents reporting difficulty accessing services were also asked why it was difficult to access the services they needed. The top reasons cited were as follows: 1. Could not afford to pay 24.7% 2. Had no health insurance 21.8% 3. Service I needed was not available 13.0% 4. I was not eligible for services 12.8% 5. Did not know where to get services 10.5% 6. Had no way to get there 9.7% 7. Waiting time to receive the services was too long 8.0% 8. Service was not accepting new clients/patients 7.0% “Other” reasons mentioned for access difficulty included coverage/eligibility limitations (0.8%), no dental insurance (0.7%) and travel/distance (0.5%). Again, it is important to note that the percentages reported above and on the chart below are the proportion of all survey respondents to provide perspective on the proportion of the whole population reporting this experience.

Figure 32.



Programs and Services People Would Use: The survey included a list of existing or potential services and asked respondents to indicate which of the programs or services they or their family would use if it was more available in their community. The top programs or services respondents would use if more available were:

1. Fitness/exercise program 49.2% percent of respondents 2. Stress reduction and relaxation classes 41.2% 3. Public transportation 35.9% 4. Weight loss program 34.2% 5. Nutrition/cooking program 30.9% 6. After-school activities for youth 28.5% 7. Job training 27.2% People who selected “medical services” were provided the opportunity to specify a medical service. The most common responses were dental care (0.7%), affordable health care (0.5%), primary care (0.5%) and ‘specialists’ ( in general) (0.5%).

Figure 33 displays the proportion of all respondents selecting each option on this question.

Figure 33.



Community Perceptions & Ideas for Building a Healthier Community :

Near the end of the CNHHP community health assessment survey, area residents were asked three open-ended questions about what they liked best about living in their community; what was most difficult about living in their community; and, if they could change one thing that would contribute to better health in their community, what would it be? In total, nearly 1,400 comments on these questions were submitted addressing a range of topics and issues. These comments were each reviewed and categorized to identify themes for each question. In some cases, comments addressed multiple issues and were parsed for assignment to different categories.

The table below shows the major categories arising from the question, “What do you think is the best thing about living in your community?”. The top theme in response to this question was ‘the people’, including families, friends and neighbors and, more specifically, a sense of community connection and community caring. The second, and undoubtedly related, theme was appreciation for living in a rural community. This theme included concepts of peace and quiet, small town living, and the pace of life.

What do you think is the best thing about living in your community? Percent of all respondents

family, friends & neighbors; helpful people, sense of community support 25%

small community, rural; quiet 17%

natural environment, outdoor activities 16%

access/proximity to services, programs; cultural activities 9%

safety, low crime 7%

good schools; educational opportunities 2%

“I love living in a rural

community because we

know our neighbors and

provide assistance to each

other in times of need.”

-Newfound area survey

respondent

“I think the people are the best

thing in the area. The area is filled

with truly wonderful people.

-Pemi River area survey

respondent

“I like living in a small

quiet town.”

-Baker River area

survey respondent

Figure 34.



The second question, which asked what was most difficult about living in their community, prompted some greater variation in responses, but also a number of responses that are the ‘flip-side’ of living in a relatively small rural community. The top difficulty mentioned by survey respondents (18% of all respondents) is the lack of transportation including lack of public transportation. The second most common theme – the long distances required for travel to work, services and activities - is related to the transportation issue.

What do you think is the most difficult thing about living in your community? Percent of all respondents

lack of transportation/public transportation 18%

travel distances to services/cost of travel 13%

lack of jobs/employment opportunities 8%

access/availability of local services (mental health and dental broken out separately) 7%

lack of physical, cultural, social activities; and related environmental supports 7%

financial burdens; taxes 6%

isolation of rural setting; lack of community connections, diversity 5%

winter 3%

lack of affordable housing 3%

alcohol, tobacco & drug use 2%

proximity to the college/college students 2%

access to mental health services 1%

access to dental care 1%

“Lack of public transportation is a huge

challenge, especially for those who cannot

afford an automobile. This area really needs

more public transportation than just the

seniors’ bus and the college shuttle.”

-Survey respondent from Plymouth

“Nothing is close - have to drive to

everything. If you don’t have a car-

it is difficult to get anywhere.”

-Survey respondent from Campton

Figure 35.



The final open-ended question asked, “If you could change any one thing that you believe would contribute to better health in your community, what would you change?” This question also prompted a range of opinions and thoughtful suggestions. Interestingly, the most common theme (11% of respondents) can be categorized as “Healthier Eating, Active Living”. This category included a variety of suggestions for community health improvement through a focus on improving food choices, including food served in schools, and increasing community resources to promote indoor and outdoor exercise. The next most common theme was more accessible and affordable health care and health care insurance. This theme is distinguished from the third most common category which addresses a perceived need for more health care delivery capacity (e.g. “more clinics”, “more specialists”). Other commonly mentioned areas for improving community health included increasing transportation options and more resources for family and community activities including a multiple comments suggesting the need for a community center.

If you could change any one thing that you believe would contribute to better health in your community, what would you change?

Percent of all respondents

healthier eating/active living 11%

access to health care/affordable care/affordable health insurance; lower the cost of care; free care

9%

expanded capacity, quality of health services 8%

transportation 6%

resources for youth, family, community social & recreational activities 6%

alcohol, tobacco and other drug prevention & treatment 4%

expanded access to mental health services 4%

expanded health education, outreach and wellness program 4%

jobs/job training 3%

collaboration, communication, community involvement 2%

access to dental care 2%

senior services 2%

economic issues/poverty 2%

“Opportunity for adults

to participate in local

activities like softball or

other sports.”

-Survey respondent

from Alexandria

“Community focus on

healthy eating, exercise,

and weight loss.”

-Survey respondent from

Holderness

“A change I would really like to see would

be for everyone to receive excellent dental

and medical care, with little to no out-of-

pocket expense because of insurance

coverage.”

-Survey respondent from Plymouth

Figure 36.



Section C Conversations with the Community (Community Leader Interviews & Focus Groups)



Conversations with the Community

Methodology: As part of the community needs assessment, the Community Health Institute

conducted a series of 22 community leader interviews and 3 focus groups to provide richness and

nuance and to validate the quantitative data collected by CHI through secondary sources and the

community survey. Community leaders were defined as residents of the service area that also play

key roles in health care or social service delivery, or work in public services that impact the

community’s risk and resiliency factors. All 10 CNHHP board members of the partnership were

interviewed and the additional 12 interviews were identified by the suggestions of the board.

Around 15 of the community leaders were identified as representing the voices of the Greater

Plymouth area, and 7 of the respondents represented the Newfound area. As detailed in the table

below, additional considerations were made to ensure as many sectors were represented as possible.

Three focus groups were also conducted as part of the assessment. The first focus group included

10 social service providers for the service area; the second focus group included 18 parents in the

service area who were part of the Whole Village Family Resource Center parent education group;

and the third focus group included 5 faith leaders in the community.

Sector Community Leader Interviewed

Education Superintendent Extended Learning Coordinator University Dean

Law Enforcement & Emergency Management Chief of Police

Community and social services Homeless Shelter Management Community Center Management Nutrition Service Management Family Resource Center Management Welfare Officer

Adult Health Care Health Center CEO Health Center Medical Director Regional Clinic Director Dental Practice Co-Owner

Pediatric Health Care Pediatrician

Emergency services Hospital Management

Rehabilitation Care Rehabilitation Centers Management

Mental & Behavioral Health Care Behavioral Health Center Management Drug Prevention Program Management

Business & Economic Development Commercial Sector Chief Financial Officer Economic Development Committee Board Member

Older Adults Senior Center Management Home Health & Hospice Management

Healthy Eating, Active Living Community Center Activities Director

Feedback from the interviews and focus groups are compiled here and organized by key themes. For

each pressing health issue identified, respondents were asked to note any existing resources working

to address the issue, and share any strategies or recommendation they had for alleviating the issue.

Figure 37.



Respondents were also asked general questions about access to care, quality of care and overall

quality of life. Focus group notes and interview scripts are included in the appendix.

The Service Area Landscape

Overall Health: When asked about the overall

health of the service area, the general consensus of the

community is that the service area is in fair to good

health overall, but with the poor population

disproportionately afflicted with poor health. All

interviewed told the story of the “haves” and the

“have-nots”-what they described as a deep divide

between those with access to health and social services and those without the needed access. The

divide is driven by factors including access to health, educational attainment, poverty status, distance

to services, and overall health/mental/behavioral status. One social service provider noted, “I would

say it’s not a dichotomy, but a disparity in the health of the community.” In response to most

questions about health indicators, community leaders expressed the great differences in these two

population groups.

Quality of Life: Similar to health status, a resident’s

quality of life is strongly driven by their socioeconomic

status. For those with health insurance and employment

there are many resources in the community that

contribute to a high quality of life, but for those who

struggle on a daily basis quality of life looks more grim.

One example given was the great economic diversity among the towns in the SAU 4 school district,

and similarly between Plymouth and nearby Rumney.

Despite the disparities, the Greater Plymouth and Newfound area are seen by the community as a

“great place to live”. Plymouth is considered a hub for arts, sports, and intellectual activities. Many

of these activities are available due to the local university, Plymouth State University. The university

has maintained around 4,000 undergraduate and 2,500 graduate students (not all based in Plymouth)

over the past five years. During that time leaders have noticed an increase in arts and recreational

opportunities mostly in Plymouth, but also in other areas. Services, activities and amenities that were

noted as important to the quality of life in the community are:

Good regional access to high speed internet

Arts & Entertainment

Flying Monkey in Plymouth

Plymouth Friends of the Arts

“There is potential for everyone in

the community to have a high

quality of life, but not all have the

opportunity to enjoy it.”

“I would say fair to poor health because it

is so hard to get health insurance that I

think a lot of people just skip it because

they figure I’m not going to the doctor,

because I can’t afford it.” –Ashland female



Summer concert series in Plymouth and Bristol

Winterfest in Bristol

Halloween parades in Plymouth and Bristol

Various programming at the Minot Sleeper Library in Bristol & Peace Public Library

in Plymouth

Various performances and gathering at the Plymouth amphitheater

Sports entertainment such as:

Teen nights at Ice Arena in Plymouth

Added recreational areas for seniors at the Plymouth Senior Center

Annual Gordon Research Conference in Plymouth

A community leader used a single night to describe the downtown vitality in Plymouth saying that in

one night the Flying Monkey had a sellout performance of 500 people; the Ice Arena sold out 800

seats for a hockey tournament; Voices against Violence sold out 200 seats at local fundraisers; and a

concert at Silver Hall had a sellout crowd of 700 people. Lines for restaurants were out the door,

and “Main Street was very alive.”

On the quality of life, many community members expressed the sentiment that ‘your life is what you

make of it’, noting that despite a resident’s employment or health status, there are free opportunities

to enjoy the local environment. A Lincoln resident expressed this sentiment saying, “Up where I

live, it is what you make it. A lot of people don’t have a lot of money, but we are up in the White

Mountains and there is a lot of stuff you can do that doesn’t cost money. Or you can sit inside all

day and not do anything, so it is what you make it.” Faith leaders added that often residents need to

be taught how to access free or low-cost activities, and that it is often a skill impoverished

individuals in the community lack. Other community members noted that they feel very safe in their

communities.

While some felt the area had a relatively slow pace of life, others noted that busy working families

have led to childhood health and behavior issues that could affect the quality of life overall. Several

noted that unsupervised children lead to increased petty crime, youth substance use, inactivity, and

unhealthy eating habits.

Some community suggestions for improving the quality of life in the area include the following:

Affordable housing in downtown Plymouth is needed for the community. A recent proposal

to build “Plymouth Woods” included six reserved apartments for low income and minimal

needs residents; however, the community leader reports that the project was canceled due to

public disapproval. Currently, homeless community members, who may not have vehicles to

commute downtown are on two year waiting lists for subsidized housing. It is particularly

difficult for single people to get housing.



Upscale condos and townhouses should be developed in downtown Plymouth for new

retirees looking to move back to Plymouth. They are an audience who might be interested in

contributing financially to community initiatives.

There are some plans to build a skate park downtown, and community members hope this

plan is implemented. They feel it will be a great outlet for local youth.

A local senior center director would like to see an expanded senior center with a pool,

washers and dryers, an activity room and a daycare. He believes the addition of a daycare

would be a valuable way for the youth of tomorrow connect with the elder population.

Several focus group participants expressed a desire for affordable after-school and

recreational activities for children, such as a local youth center, and more flexible day-care

options.

There should be more activities available for high school students.

A faith leader emphasized the need for outdoor activities for youth that don’t require a car,

such as more playgrounds accessible by foot or bike. Low cost or free skiing for youth, and

additional community gardens were also recommended.

Economy: The economy is seen by many as an ongoing risk to the health of the community.

Much of the area's seasonal employment has seen a decline as a result of the recession, including the

closing of Tenney Mountain Ski Area. Those who still have seasonal employment face high job

insecurity and no insurance coverage. Additionally, the rural area makes it more challenging for

residents to travel for employment opportunities. Unemployment and lack of insurance coverage

have launched many residents into what they call “survival mode”, focusing on day to day necessities

often leaving preventative care to the wayside. A social service provider commented, “Basic survival

is more of a day to day struggle [for the poor] so they can’t even conceive of going to a doctor

regularly, or do wellness visits, because they are in a survival mentality.” A Plymouth area resident

reported the following:

Additional consequences of the economic recession that were identified include the following:

A local police department reported higher rates of depression and suicidal thoughts as a

result of joblessness.

“I was the owner of a company for about 16 years, but because of the economy it went belly

up about 2 years ago; since then I have been unemployed. I think the economy has a lot to do

with what’s going on…especially around here. I think that is the prime factor – people have to

survive. That is what I have been doing the last 2 years. I will do whatever I can do, because

that is the only way to make money. That is my prime thing – trying to figure out how to make

money. All the other considerations, health insurance, everything, it just doesn’t even matter.

- Plymouth area male



Homelessness continues to be an issue in the service area. The Bridge House, a co-ed

homeless shelter in Plymouth, is currently over capacity for its male clients. In describing

those that seek shelter services, a community leader said, “Participants in need of a homeless

shelter in Grafton County have exhausted all financial and social resources. They are not

people that have just recently been laid off, but people that have tapped every friend and

family member for a couch to sleep on.”

Patients are ending up with piles of back bills that they don’t know how to deal with.

New initiatives in the service area that are addressing the economic downslide include the following:

The Plymouth Regional Chambers of Commerce recently started a Central New Hampshire

Young Professionals Group that tries to support and encourage young professionals in the

area to be involved in business opportunities and keep talented youth in the area.

PSU is seeking funding to start a business incubator that encourages college students to stay

in Plymouth and foster their business ideas.

The Bridge House started a gift shop to teach homeless clients retail skills.

Waterville Valley Ski Resort was recently brought back into private hands, and the owners

are making a big commitment to return it to a more rural family based NH setting.

Ashland Lumber is building a new expansion in the area.

Community leaders and members also provided suggestions for ways to

stimulate the economy:

Stimulating tourism in the area would increase revenue for local

businesses and seasonal housing without putting a burden on

public resources like schools, and health services.

Plymouth should promote itself as a place to stop for amenities along highway 93. A

community leader noted, “Plymouth is the first real hamlet you see on your way up 93.

There is no prettier setting than that little town of Plymouth.”

Someone like Alex Ray or other culinary leaders in the community could start a culinary job

training program that that teaches cooking skills and general food service skills for residents

that are unemployed or homeless.

There should be a greater focus on alternative education, including vocational training

programs and apprenticeship programs. Trades are a valuable option for kids that don’t want

to go to college.

Transportation: Transportation continues to be a

challenge in the service area’s rural environment. With

virtually no public transportation, residents are dependent on

their automobiles and are often prisoner to severe weather

conditions. Transportation limitations seem to be felt

“NH is a tourist economy

and Plymouth is on the

fringe.”

“Access to transportation affects

everything from getting to a doctor

or dentist appointment to holding a

job.” –welfare officer



particularly strongly by Newfound community members who feel that people and services are often

great distances from each other. Community members and leaders specifically mentioned the

following transportation considerations:

Students from all over the Newfound area come to Bristol for school, which makes busing

and transportation for after school programs a logistical and financial challenge. When not in

after school programs, most Newfound area students are limited to their houses and are

limited to social life on their computers due to an inability to get to each other without a car.

Service providers added that transportation to get to employment trumps any kind of

transportation to health care or mental health. Using the car to get to work and put food on

the table is more of a priority than using the car for health care. Community members agreed

noting that despite some existing resource for medical transportation, more convenient and

accessible options are desirable.

A local law enforcement official noted that criminals in the area consider revocation of their

license for two years to be far worse punishment than spending 30 days in jail.

The only public transportation services identified by respondents were the Plymouth Senior Center

bus and the Plymouth State University shuttle which takes passengers to the Wal-Mart in Plymouth

and to Mid-State Health Center. Individual organizations have taken measures to help alleviate some

of the transportation problems among their constituents. One dental practice co-owner offers

support to longtime patients by having a driver pick them up for appointments when located nearby.

A local faith fellowship has implemented an “extended family committee” which helps fellow

parishioners get to medical appointments.

One recommendation for a way to improve the system is implementation of a RideShare program,

where people could rent cars for specific periods of time.

Collaboration: Leaders in the community feel there is a

strong spirit of collaboration among organizations in the service

area and a similar enthusiasm for community support among the

residents. A Bristol service worker commented, “There is great

collaboration out there. If you just call them, you will get some

help in some way.”

Of the community, leaders said:

“You’d be pressed to find a community more dedicated and spirited about volunteerism.”

“The partnerships and organizations in the Newfound area work together, play together and

pray together.”

Initiatives and events like the local old home days, community fundraisers, and sports

leagues do a lot to bring the community together.

“There is a real spirit in this

town. At Christmas time, the

local residents roll up their

sleeves and decorate the main

street and the rest of the

town.”



A community leader involved in economic growth for the

area noted, “We are getting better at working together as a

medical community…we are not competing for patients

anymore.”

Parishes and fellowships in the area organize “extended

family committees” and other support groups for their

community.

Role of CNHHP: Leaders are continually impressed with the

talent in the Central NH Health Partnership and recognize its

significant growth in the past five years. The partnership is seen by some leaders as an open and fully

collaborative partnership. Leaders note that collaboration through groups like CNHHP is essential

with the explosion of non-profits in the area. Where there used to be only a few local non-profits,

now there are about 15 non-profits all vying for the same funding.

Among those leaders who worked closely with the Newfound area, several noted the challenges of

overlapping health partnerships. CCNTR (Caring Community Network of the Twin Rivers) and

CNHHP (Central NH Health Partnership) both serve Alexandria, Bridgewater, Groton, Bristol,

Danbury, Hebron, and New Hampton. While some note that this overlap affords these

communities additional programming and funding opportunities, others feel that the overlap feeds

confusion and competition. One Bristol area leader described feeling as though the two partnerships

want to be associated with the Bristol area when it makes for a better application, but don’t when it

isn’t to the partnership’s benefit.

Some comments from the community on the benefit of the partnership include the following:

“The Central NH Health Partnership is the top of my list [for promising new efforts being

done in our community].”

Community members specifically noted the high level of communication and coordination

between health care organizations. As a focus group participant noted, “The network that

Plymouth has for social services is a lot tighter and a lot more in-depth than what the

Laconia-Meredith area has . . . . So I definitely got to give this community ‘props’ for that.”

A local leader in health services noted that she has seen an increase in health education and

physician education through the partnership.

Some strategies and recommendations for sustaining and enhancing the partnership include the

following:

“There is a push and pull

between the regions over

who gets us- sometimes

[they] want our region and

sometimes they don’t.

They only want you when

it will help their numbers.”

-Newfound area resident

“We [CNHHP members] are partnering for the health of the community.”

–board member



The partnership should consider conducting needs assessments, engaging in collaborative

planning, and establishing quality measures for the partnership.

The partnership should span both worlds of clinical services and public health.

The partnership should consider its own sustainability, since it takes so long to get new

players and leaders to the table.

Pressing Health or Health Care Issues

Active Living: Community leaders from across the sectors continually identified an overweight

population and high rates of obesity as one of the most pressing health issues facing the service area

community. Service providers see both adult and childhood obesity as serious risk factors for future

health issues. One interviewee shared results from a recent measure of BMI counts at New

Hampton Community School, which found that 50% of 3rd and 5th graders, and 21% of Newfound

area kindergarteners are overweight or obese, and 21% of Newfound area kindergarteners are

overweight or obese.

A shortage of fitness facilities and a resulting lack of enough exercise by residents are among the

primary reasons for obesity identified by local leaders. This perspective is supported by responses

from the community survey, which reports that nearly 36% of respondents identified “not enough

exercise” as a pressing health issue in the community.

Resources and services in the Greater Plymouth community that are trying to address this scarcity

include the following:

Ninth State is a small fitness complex in Plymouth that offers popular exercise programs like

boxing and spinning, as well as dance classes. Due to the cost of membership and the

limited facility space, it does not meet the needs of the whole community.

Speare RehabFit was also mentioned as a valuable new addition to the service area, although

membership dues again limit accessibility.

Community members noted that both the pool at Plymouth State University and a motel

pool off exit 27 are open to the public.

The community spoke with great anticipation and excitement for Plymouth State

University’s Athletic and Wellness Center development project, which plans to bring an

indoor track and pool, turf field, and wellness and research center to the town. It is likely

that the community-at-large will have the option to pay to use these services.

Several community members and leaders identified the PSU Ice Arena as an important

facility for promoting physical fitness.

Even more so than the Plymouth area, Newfound residents suffer from a profound lack of indoor

fitness options. With the only exercise program in town now closed (Curves), resident’s closest



option for a fitness center is the Planet Fitness in Belknap. In recognition of this deficit in services,

local organizations are offering the following services:

Tapply Thompson Community Center is currently running a Biggest Losers fitness program

called “Newfound Losers”. The community has expressed great interest and enthusiasm in

the program with a 2010 enrollment of 144 participants who lost a combined weight of

1,025.25 lbs. Tapply Thompson runs three sessions of Biggest Loser each year, for 12 week

sessions. Since the program began, Newfound Losers participants have lost a total of over

5,000 lbs.

Additionally, Tapply Thompson runs a twice weekly exercise class that 20-30 people attend.

The 1.7 mile multi-use walking path in the Newfound area is a useful all-year round fitness

resource for residents.

Revitalization plans are in progress to make Bristol downtown a more walkable community.

The Newfound area has recently enhanced some of its outdoor recreation areas including

Kelly Park.

In the schools, the teachers and administration comment

that increased demands on scholastic achievement have led

to reduced recess and physical education time. All of SAU 4

shares just one full-time and one part-time physical

education teacher. Fourth and 5th graders at Bristol

Elementary school no longer have recess and only have

physical education once a week. One initiative to address

this change in school programming is development of safe

walking routes to school in Bristol and development of a

walking track at a local park.

The community expressed a strong desire for a large indoor fitness center. When asked what they

would spend $2 million for the community on, most community leaders said a fitness center. Some

other suggestions to foster active lifestyles include the following:

One leader suggested the inclusion of a fitness membership reimbursement program for

HealthyKids subscribers, as well as subsidizes or incentives for eating healthy food.

Several leaders noted the need for an exercise and activity space for elders in the Newfound

area.

Parks and playgrounds in the area should be better designed for younger children, and more

strategically placed playgrounds should be added to the community.

A Plymouth resident suffering from chronic pain expressed a desire for personal training

services to help manage the pain with exercise.

Financially and geographically accessible outdoor activities such as neighborhood parks and

gardens and low-cost skiing would be potentially valuable assets to the community.

“Physical education is not made a

priority in the school system. The

students are only getting 45

minutes of physical education a

week; however, the national

standard is 60 minutes a day.”



Healthy Eating: Lack of good nutrition and nutrition education was the other major factor

identified by leaders as a cause for the overweight and obese population and was identified as a

pressing health issue by 34.7% of the community survey respondents. The Bristol area used to have

a WeightWatchers, but since closing residents have to commute to Plymouth to attend

WeightWatchers meetings that help them stay on target with healthy eating behaviors and weight

loss goals. A Plymouth area resident reported that Ninth State offers a “Weigh to Go” weight loss

class on Mondays.

Additionally, the nutrition of the senior population is of concern to

some service providers. Many of the area’s older adults, in particular

widows, rely on a local senior center meals and meals on wheels for

one nutritious meal a day, and are unable to provide well-balanced

meals for themselves at other times.

The school systems and youth programming are described as making

good progress in efforts to offer more nutritious food, although some

contend that the school meals are still too focused on convenience and speed of preparation rather

than nutrition. For students on subsidized meals and/or those that have breakfast at school, the

nutrition of these meals is important for the student’s brain development. School administrators are

reporting higher rates of students with Type II diabetes, which also has implications for the meals

offered to students.

Community leaders note the critical need to educate both adults and youth about healthy eating

habits. Many identified this lack of health education, as a bigger driver of poor diets than income or

time. A faith leader noted that people need to be taught how to take personal responsibility for their

health. Unhealthy eating and cooking habits affect the whole family. Social service providers report

that many families find it difficult to take the first step in

learning how to cook healthy meals. They find comfort in

packaged, familiar foods. Budget cuts are a barrier to

offering this much needed health education to students

and families. A school administrator expressed frustration

with the school budget committee’s ongoing attempts to

cut funding for a health teacher and school nurses.

The service area has several innovative programs to bring

healthy meals into the schools and back to the homes.

Some of those services and initiatives include the following:

The Newfound area schools continually submit grants for funding to build healthier school

lunch menus.

Danbury Elementary School is running a Crock Pot Program where students assemble meals

and bring them home in crock pots for family dinners.

“We need to help the community

understand the role of school

nurses. In tough economic times,

the nurses are sources for more

than regular care. They are the

children’s doctor.”

–school administrator

“There is something so

unfamiliar [to parents]

about utilizing good

foods.”

–social service provider



Wal-Mart and the Food Bank have implemented a “Backpacking Program” that sends

students home with meals in backpacks.

Newfound High School is running a cooking club for students.

The Newfound Regional High School now offers dinner to students once a week, and

healthy snacks every afternoon.

Tapply Thompson Community Center has removed all vending machines and provides low

calorie snacks and 100% juice drinks.

Gardening groups, such as the Master Gardeners and ELFS (eco-learning farmstead), are

working to create a family-friendly, active and nutritious environment.

In addition to WIC and food stamps some NH initiatives helping to make food affordable

for service area residents include the following:

NH Food Bank and Catholic Charities support the Newfound area’s lunch

programs.

Bristol Shop & Save plays an active role in the community and sponsors school and

community events.

United Way (formerly Whole Village Family Resource Center) provides subsidized

groceries to families.

The Plymouth Senior Center provides 50-60 meals in its dining hall each day and

another 150 meals on wheels out in the community.

Nutrition Connections provides cooking lessons with parents and children at various locations. The program also does individual outreach to get to parents who may have a hard time taking that first step.

While many new programs in support of healthy eating have begun in the past few years, leaders had

several ideas for future programs that could address the need for healthier diets including the

following:

A health food store and restaurant could be opened at Boulder Point to compliment the new

Speare RehabFIT.

An “Overeaterers Anonymous” group for the Newfound area residents could be established

for those in the community in need.

Dental Care: Fifty percent of respondents on the CNHHP

Community Needs survey identified access to dental care as a

pressing issue in the community. There were mixed opinions on

the capacity of the dental providers in the area. One dental

provider noted that with seven dentists in the area, there should be plenty of capacity to serve the

residents in the Plymouth area. Others described difficulty getting dental appointments, even with

dental insurance. Many identified an unmet need for oral surgeons and orthodontic care.

Not only are there a limited number of dentists in parts of the service area (and none in the

Newfound area), but very few offer dental services to patients with Medicaid or without insurance

“I know the difference when

someone has lost their smile

because of their teeth.”



coverage. A dental practice co-owner interviewed noted

that there is only one dental facility in the area that accepts

Medicaid. Dental practices are reluctant to accept Medicaid,

because of extremely low reimbursement rates and strict

parameters on the dental services that can be provided. A

dental practice co-owner commented, “We would like to

hook up with the hospital to get full reimbursement [for Medicaid patients]…A $250 extraction now

only gets $80 in Medicaid reimbursement. Medicaid [only] does initial exam, x-rays and extractions.”

The co-owner gave the example of a mentally ill patient on Medicaid whose condition made regular

dental cleanings important, but the service was not covered by Medicaid. Furthermore, Medicare

doesn’t cover any dental care except injury to “sound and natural teeth”. The co-owner also

reflected on the unfortunate situation of disabled clients who age out of HealthyKids and are no

longer eligible for comprehensive dental coverage.

Children on HealthyKids insurance are able to get preventive dental care, but many apparently still

do not get the preventive care they need. A school administrator noted that several of his/her 7 year

old students needed tooth extractions this year. For youth not enrolled in HealthyKids, the cost of

dental care without insurance is very often cost prohibitive. Even tooth extractions are a significant

financial burden for many residents. In some cases, noted a local service provider, residents need to

make the choice between paying for heat or paying for dental care, and during cold winters they are

likely to choose the heat.

A community leader noted that a reason for low dental insurance coverage rates is that there aren’t

large enough employers in the area to support employee dental insurance programs. It was

commented that even though Wal-Mart provides dental insurance, the co-pays in the plan make

dental care not affordable for its employees.

Additionally, no dentists are reportedly available on a 24/7 emergency basis. Residents with

emergency dental care needs are typically directed to the Speare Memorial Hospital Emergency

Room where they are treated for pain until they can get in to see a dentist.

The community noted several initiatives providing dental care to school age children but were

unable to identify many dental programs to address adult dental care needs. The initiatives noted

include the following:

There is a Plymouth dental hygienist who does dental hygiene practice trainings for primary

care, as well as does work in the school systems.

“I can’t eat sweets, because there

is no money to go to the dentist.”

– as told by a child to a local

service worker

“We just had an incident because dental is not covered. He is on Medicare and dental is not

covered…He had teeth to be removed. [It was] not covered and it slammed the family so

hard, and it was like ‘Oh my God! What do we do?’” –Ashland female



Several communities provide school based dental examinations and cleanings.

A Newfound area nurse conducts dental screenings in the schools on a regular basis and

refers students to dentists.

The Bridge House, a local shelter, tries to identify a “Floss Boss” who is responsible for

checking that clients are flossing their teeth.

A focus group participant shared that adults can get free or reduced rate dental care from

dental students at NH Technical Institute.

There used to be a dental task force, but it was described as “talking in circles for years

deciding what to do”.

Recommendations for improvement of the dental care system include the following:

Local service providers should develop a rotation of dentists willing to do community

service and examine local kids that have never been to a dentist before.

The Emergency room should be staffed with a dentist. One leader notes that drug abusers

frequently have serious dental problems, and when the only treatment option for them at

emergency rooms is painkillers it can have devastating consequences.

A dental provider recommended a dental insurance pool that provides funding for the poor

and uninsured in need of dental care. The insurance pool would be for residents in-between

getting insurance from employers, but who don’t meet the eligibility criteria for Medicaid. At

a minimum the pool would fund fillings and extractions.

Mental & Behavioral Health: As shown in the survey response summary, 34.4% of survey

respondents identified “access to mental health care” as a pressing health issue. Over 37% and

34.1% of respondents noted “adult alcohol and drug use” and “youth alcohol and drug use”

respectively as pressing health issues. During the parent focus group, numerous community

members noted their reliance on Genesis Behavioral Health services, and described a fear of budget

cuts restricting their access to services. Focus group participant’s comments on mental health

services include the following:

A Plymouth resident said, “I go weekly [to Genesis]. I mean it just really helps. Especially

people who go through tons of grief and transition. To hear they [Genesis] are getting a 50%

budget cut…People already can’t afford the co-pay.”

A male resident from Lincoln added, “Up in the Lincoln-Woodstock area, it’s a small

community, but there is no real mental health providers. It’s not really an impoverished area,

but a lot of people are probably living close to the poverty level. It’s seasonal employment,

so no one is getting any benefits. And there is no mental health. And I know with the

economy the way it is people are just living season to season and there is a lot of stress there,

but there is no way to really to cope with it.”

While noting the valuable role Genesis Behavioral Health play in the community, community

members and leaders describe a need for other types of mental health services such as psychiatrists,



licensed alcohol and drug counselors, emergency mental and substance use treatment services, and

outpatient mental and addiction services. Expansion of mental and behavioral health services is an

important focus for the area, with higher than state average youth alcohol and substance use rates,

and high rates of hospitalization and ER visits related to mental health conditions. Community

leaders also noted that depression is a prevalent mental health condition in the area. One youth

service worker said that children at their organization with depression issues don’t get the services

they need, because a) they don’t have health insurance, b) can’t access the services, or c) don’t know

how to start handling the problem.

Many leaders spoke of the capacity deficit for mental health services in the area:

“Mental health is a huge deficit. We have students all the time that need substance abuse and

mental health treatment services. For those that need treatment, there is nowhere to go. The

closet is Laconia and Plymouth.”

Some leaders noted that there are no psychiatrists in the area. Others thought that there are

psychiatrists in the area, but that there are none that accept Medicaid or have a sliding fee

scale.

A local police official described the lost time and

frustration of navigating a suicidal or unsafe resident

through the medical system. The official described

waiting for up to 12 hours and 13 hours on the last

two cases at Speare Memorial Hospital waiting for

someone that could evaluate the resident’s mental

health status and admit the patient to the State

Hospital.

It was noted that there aren’t enough mental health

counselors available in the community and that they

aren’t accessible to families without the school system

stepping in. Additionally, for those with insurance only 5 sessions are covered, which doesn’t

meet the counseling needs of the family.

Several community members and local leaders pointed out that it is harder to get anonymity

when seeking mental health services in a rural community. Several noted seeking care in

other communities so as to be more discreet.

“Access to mental health care is not anywhere near where it should be. Even those with

insurance and jobs are reluctant to seek out mental health care they might need because they

know that they might only be able to go for eight sessions [before their coverage runs out].”

–faith leader

“If you went to a hospital and

you thought you had sprained

your ankle…would they have said

‘no, we don’t treat sprained

ankles. Go away.’ … I just feel like

the standard of care is different

for mental health, and it might

not be if there was a psychiatrist

available in the community.”



A faith leader described the challenges one parishioner faced in getting a video-conference

psychiatric evaluation. It was noted that it seemed like requesting a tele-medicine evaluation

was a difficult hurdle for an individual suffering with mental health problems to address on

their own. Having family advocates was essential to pushing the hospital to set up the tele-

psychiatric session. It was also noted that the tele-medicine felt disconnected and that the

patient was not getting the level of care needed.

Co-occurring diseases and disorders such as mental health conditions and substance abuse are

similarly lacking in capacity. On the issue of substance use, community leaders note the following:

“From what I’m hearing from the schools, drug use (especially marijuana) is on an up-swing,

and with earlier age of onset in middle school.”

A school administrator noted that it is nearly

impossible to find a Licensed Alcohol and

Drug Counselor to work at the local schools

and that the students are in great need of

prevention and early intervention services.

Prescription drug use is increasing across the

service area, particularly among young adults. A

home health worker noted that young adults

are raiding their grandparents medicine

cabinets. Older adults have many prescriptions

that they are not using but don’t know how to

dispose of.

Smoking, it is noted, continues to disproportionately affect the low socioeconomic

populations. One service provider noted that her clients use smoking as a dopamine fix to

self-medicate.

A local prevention worker noted that there is an increase in alcohol poisonings in the area.

Plymouth and Easter Seals rehabilitation centers are always full, and Webster place does not

accept health insurance, so there are many residents in need of addiction treatment services

that cannot access it.

On detox and mental health services, a Plymouth resident commented, “…The detox is a

whole 30 days. I’m sorry, but my daughter needs

more than 30 days…There is nothing around here

that can handle both mental health and substance

abuse services simultaneously.”

A local leader said, “When I talked to an area

provider a while ago, they had a two month wait

period [for addiction services]…If a young mom

comes in for financial help and I can tell by looking at her that she is using

methamphetamines, I’d like to be able to say to her ‘here is a check for the grocery store

“If we don’t get the drugs, alcohol

and smoking under control then

down the road these people will

have multiple, multiple problems.”

“My daughter had gone to {a drug

treatment provider}and she owed them

money. And they kept saying ‘well you’ve

got to pay this’. She doesn’t have any

money and I certainly don’t have any to

give her. So because of that she got no

help and she went back down here and

back to her old tricks.”

–Plymouth female



AND also can I help you make an appointment with an addiction center…There is nothing

now except sending her to AA… or Narcotics Anonymous.”

One person noted an inability to find an open short term detox program for his brother. It

was noted, “So here he is a year later and hasn’t done anything…it doesn’t sound like a

solution to me.”

Several initiatives for expanding mental health services were identified by the community leaders:

The Center for Adolescent Health out of CHAD and Plymouth Pediatrics and the

Adolescent Treatment Initiative (ATI) are working to change the mental health delivery

system and working to support care management that is: timely, patient and family centered,

integrated with other aspects of health care, evidence-based, when feasible, and outcomes

driven.

The new therapist at Mid-State Health Center is seen as a great addition to the health center,

and many wish the therapy services were accessible to non-MSHC patients or that

comparable services were available elsewhere.

CNHHP is undertaking an initiative to bring in a family clinician from Family Strength. This

is seen as an important step in bridging the gap between primary care and mental health.

Step by Step is a new program providing early mental health services to 0-3 year olds and

their families. Parents are more willing to participate since it is seen as something for their

child.

Newfound and Plymouth High Schools are increasing school-based support services with

additional counselors, social workers and a high risk youth team.

There are ongoing initiatives to connect the homeless population with mental health

services.

Rather than holding meetings to discuss the health issues of individual students, school

teams and providers have been engaging in collaborative discussions about how to address

public health and medical and mental health issues such as suicide prevention and youth

homelessness.

The area has also recently started a mental health court-in three districts in the county, but

the service is not available yet in Alexandria’s district court.

An ongoing focus on the medical home will aid people hesitant to seek mental health

services due to the stigma around mental health issues. An individual will go to the same

place for care regardless of whether it’s for a primary care visit or therapy appointment.

A focus group participant noted that Grace Counseling, a pastoral psychotherapy practice at

Plymouth Congregational Church, offers affordable care to patients on a sliding fee scale.

Faith leaders noted that the chaplaincy program at the hospital is a relatively new (2.5 years)

program that serves approximately 40% of those admitted to Speare Memorial Hospital.

Eight local clergy volunteer to visit with patients interested in speaking with someone from

the faith community. It was noted that other more developed chaplaincy programs include



notes from the chaplain’s patient visit in the patient chart to provide a well-rounded patient

record.

Additionally, the following substance use prevention and treatment services were identified:

NANA provides educational materials for the public on how to dispose of leftover

medications.

The Newfound area is holding community discussions and parent education classes around

substance use.

A few years ago, Bridge house clients started an early morning Alcoholics Anonymous

meeting, which is now attended by a number of community members.

A drug court program has started in Grafton County, which provides alternative sentencing

for non-violent drug offenses.

The Alexandria police department is hosting a drug take back day (D-Day) at the local

transfer station. Residents can drop off old and unused drugs that the VA will pick up.

Without the VA as a resource for drug disposal, the police department would be unable to

do any drug collection.

A service provider noted that, “Over the past two years regionalization of the prevention

system has been big for our community, and gets more information out there. It continues

to grow.”

Some suggestions and recommendations for improving the mental and behavioral health system in

the area include the following:

The community should invest in a substance abuse residential treatment facility for youth in

the area.

The local health services should partner with Dartmouth-Hitchcock to bring in psychiatry

residents to provide services in the area.

There should be more collaboration with physicians to curb redundancy in prescriptions and

the corresponding abuse by residents.

There should be a regional version of 2-1-1, or a regional care coordination call center to

connect people with 24/7 mental health and substance abuse treatment services.

o Faith leaders noted that they are often the first people to learn about a resident’s

mental health or substance use problem, and they want to feel confident in knowing

how to connect that individual to appropriate services.



Elder Care: Limited capacity for elder care is an ongoing concern for the service area. With a proportionally high elder population, it is important to consider the needs and gaps in services for this population. Some of the gaps in services identified included the following:

With limited options for assisted living in the area, many families are caring for their older parents and grandparents. Community leaders note a lack of respite services for adults in this situation. They express a need for more support systems such as transportation and day care programs.

A hospice service provider added that there should be more support available for end of life care.

There is an ongoing and growing need for long term care and assisted living.

Access & Quality of Care

Access to Care: When asked to rate access to care on a scale of 1 to 5, most community leaders and members gave it a rating of 3, with the next most frequent rating being a 4. Health insurance coverage directly impacts an individual’s ability to access care. With a high uninsurance rate of 18% in the service area, access to care is a serious problem to address in the community. Additionally, access to health care is affected by many other factors including: quality of insurance coverage, availability of necessary services or technology, capacity of service providers, flexibility of hours of care and transportation. When speaking of access to care almost every leader gave the qualifier “for a rural community”. ‘For

a rural community’, they said, ‘access is good and the health services are progressive.’ Again the issue

arose over the “haves” versus the “have-nots”, and how poverty in many ways becomes a barrier to

timely and affordable access to care. In the Newfound area, it was reported that only two family

practitioners accept Medicaid patients, and in Plymouth it was reported that it’s hard to find

providers accepting new Medicaid patients. Throughout the service area dentists refuse to accept

Medicaid.

Loss of earnings or even unemployment is a serious

consideration for many parents that need to leave work to

bring their child to an appointment. Often a broken car or

no access to a car prevents patients from making

scheduled visits. As one provider put it, “The thing that

they’d like to do is maybe the thing that they can’t do,

because they can’t afford to lose their job. So they have to choose between services for their child

and making sure they have food on the table and a place to live, and that seems not right.”

“The rural-ness of the community

prevents people from getting where

they need to go, whether it’s

transportation related or weather

related.” – social service provider



In general, community members discussed frustrations with long rides to services not available

locally; long wait times in the waiting room; and some miscommunications with pharmacies. Some

of the existing services and gaps in services considered when rating accessibility include the

following:

Community leaders and the community-at-

large feel very comforted by the emergency

helicopter services. Numerous leaders said it

made them feel more comfortable seeking care

at Speare Memorial Hospital knowing that they

could be airlifted to Dartmouth or another

hospital if special care was needed.

The Community Care (NH Health Access)

program provides financial assistance in accessing care in the community, including

emergency care, gynecology and prescription coverage. When mentioned during the

community focus group, only 3 of the 18 participants were aware of the program.

Access to specialty care, such as orthopedics, cardiology, oncology, and neonatal care, is

limited but has improved over the years. Also, relationships with larger health care

facilities like Dartmouth and visiting specialists make it easier to access specialty care.

•In conversations with the general public, it became clear that there are potential issues around lack

of information regarding what services are available in the community, as well as expectations

regarding the type of resource-intensive specialty services that can be adequately supported locally.

When thinking about the variety of care accessible to them, community members said the following:

Plymouth area residents feel there are good alternative medicine practices, such a

chiropractic, available in the community but that services are often times cost prohibitive

because insurance does not cover it. In the past year, Plymouth hosted an alternative

medicine fair.

The Newfound area feels that there is not access to alternative medicine in their

community.

One leader noted, “I feel like there is so much out there, and yet I’m constantly meeting people that don’t know what is available or don’t take advantage of it.”

Some Newfound residents view access to the three regional hospitals in Plymouth, Franklin and Laconia as an asset to the community, allowing patients to have more choices for care. Others express a desire for a hospital in their own community.

A leader expressed concern over new regulations that require more steps for a physician to refer a patient to home health care, which may result in decreased access to home health services for needy patients.

Community members are in strong support for early intervention programs, such as Lakes Region Community Services. They noted that such services are extremely valuable resources to them as parents. Many wished services continued for longer into the child’s development.

“Anyone that wants to get

healthcare is going to get it on an

emergency basis, but regular day-

to-day care is much harder to

access.”



The culture of poverty is another issue that some perceived limited access to care. The culture is one of Yankee Pride, and this community has difficulty navigating the system. On the “culture of poverty”, interviewees and focus group participants make the following comments:

“Either it is a pride issue or an awareness issue, but so many people don’t seek out services when they need it- and that’s all types of services: medical, mental…”

There are several new roles helping to provide care coordination and family support to community members including a support specialist at Mid-State Health Center and family services coordinator at Lakes Region United Way (formerly Whole Village Family Resource Center) that provides care coordination services to patients and providers, such as helping with transportation and housing.

Access to medical devices and prescriptions is also a challenge for many residents. Even with insurance, prescription co-pays can be cost prohibitive, or travelling to the closest pharmacy may be a challenge for some immobile populations. On access to prescriptions, community leaders and members note the following:

Access to medicine has increased with the development of a Rite Aid in Bristol.

One leader summarized accessibility for elders as follows, “Seniors have three main cost

concerns: FOOD-FUEL-MEDICINE. I think pills are purchased last when a senior has to

make a financial choice between the three.”

Older adults struggle to afford medical services. An elder services worker noted, “There isn’t enough insurance to cover the health of our seniors, in particular dental care. Teeth are the biggest problem I see.” He also noted a huge problem with affordability of hearing aides and vision care, noting “It is out of the elder’s range.”

The Prescription Card is a new program in the community that partners with large scale pharmacies to offer reduced cost prescriptions to the uninsured.

Community Care (NH Health Access) also offers a prescription program. Of that program a local resident exclaimed, “If it weren’t for them, my husband would probably be dead… I have never been more grateful for anything in my life.”

Community leaders shared the following recommendations for improving access to care:

The region could implement a MediBus that picks children up at school for well-child visits.

A local physician commented, “Looking at friends and family that have cancer, it would be nice to have radiation and oncology locally available. It’s a challenge to have to drive to Hanover for treatment so often.”

The local school administrators said they want to support the community in any way they can, such as by hosting well-child visits at the schools on Saturdays.

One leader would like to see a HealthCare for Homeless model implemented in the local shelters that include visiting psychologists and nurse practitioners.

Telehealth was mentioned by some as a potential tool to increase accessibility, but with notes of skepticism. Several leaders feel that telehealth may further isolate rural residents and depersonalize their care. Additionally, those that are most disenfranchised are the least likely to take advantage of the telehealth, because they don’t have the patterns of behavior to know naturally where to go and how to access services.



Quality of Care: When asked to rate the quality of health care in the community on a scale of 1-5, the most popular answer was “4” followed by 5 for excellent quality of care and 3. Similar to access, leader’s measures of quality were tempered by the rural nature of the service area. Some of the leader’s thoughts of quality include:

“A town for our size and location has a very

progressive hospital with progressive services.”

Additionally, a community leader noted, “We are very

lucky to have what we have, even if it is understaffed

sometimes.”

One leader added that when the hospital is unable to afford

something such as an MRI machine, they bring it in weekly for

patients.

Said a community leader, “The physicians seem to care as much

about the community as the rest of us.”

One member of the medical community proposed that “Primary

care [in the service area] is awesome, and is as good or better

than the rest of the state.”

A local social service provider exclaimed, “It is incredible what everyone is doing with the

available services. Genesis has divided its people into two! The reason I would scale it down

from 5 to 4 is the lack of dental services.”

Several leaders noted that the new facades at Mid-

State Health Center and Speare Rehab Center, as well as

community bulletins and news updates, help prevent any

perceptions of services being rural or basic.

Several noted that Mid-State Health Center’s move

to Boulder point with the Rehab center increased

integration of services and was more “holistic”.

One health care provider noted that the service area

is a very hospital oriented community, and that quality of

care could benefit from moving more towards care at

physician’s practices and medical homes. Another medical director added the medical homes

need to be established “so nothing is forgotten or left behind”.

People with chronic conditions are continually readmitted to the hospital because there isn’t

appropriate care coordination after a patient is released from the hospital.

The service providers’ medical records don’t speak to each other currently, because they all

use different vendors. In order to improve care coordination, medical record systems should

“be like ATMs” where you can access information regardless of the company.

“In my personal experience as

a nurse and with a partner

who is a physician, Plymouth

has a very forward thinking

hospital…that has been

implementing best practices

for years.”

“Several years ago, I

wouldn’t have gone to

Plymouth for any life

threatening issues. I

would have gotten

myself in the car and

gone somewhere

else.”



Many leaders note the challenges of recruiting and retaining doctors in the community, because of

lack of employment options for their spouses, lack of urban amenities such as shopping malls, and

inability to offer competitive salaries. Health service providers like Mid-State Health Center and

Speare Memorial Hospital are seen as taking good steps towards making employment with them and

in the community more desirable. For example, Mid-State Health Center added a Montessori school

within its building so medical staff can have their children close by.

Health education is recognized as an important part of high quality of care. Similar to preventative

care, health education helps prevent risky behavior that may lead to health issues in the future. The

challenges of getting people to participate in health education programs include the time

commitment of attending programming outside of business hours and the potentially long drive for

those outside of Plymouth. Workplace wellness programs were one identified strategy for reaching

residents with health education, since people are less motivated to attend programming outside of

business hours. For example, PSU’s 400 employees are provided wellness programs, incentives, and

cash-back for participation in wellness activities and events.

Some other initiatives mentioned by the leaders that are addressing quality of care are:

Establishment of an accountable care organization to focus on positive outcomes for

illnesses and reduced costs.

One leader noted how unique it is to have doctors in the area that still do home visits.

The Newfound School system is putting together a community health fair.

Several leaders noted the benefit to the community of having the new therapy pool and

water exercise programs at Pemi-Baker Community Health.

Suggestions for addressing any gaps in the quality of care include the following:

The delay between intake and start of services for mental health patient’s needs to be

quicker.

Health care providers should continue to bring health care to the people, rather than

expecting them to always come to the providers. This can be accomplished through things

like community based immunization and flu clinics.

Providers can develop recognition and incentive programs for patients that engage in a

healthy lifestyle.

Encouraging development of more private practices, with doctors not working for fee-for-

service was noted as ‘something to be desired’.

Continue to focus on development of medical home so patients can have “one stop

shopping” and “don’t have to be referred out of their comfort zone.”



How to Use $2,000,000: Community members and leaders were asked if they were given $2 million to spend on any one thing that would contribute to improved health in the community, what they would spend it on. The following table compiles their responses.

Category of Services &

Amenities

How Community Leaders Would Use $2M

Mental & Behavioral Health

Services

Hire LADC (Licensed Alcohol and Drug Counselors) to “get on top” of substance use issues in the school system.

Increase access to and capacity of mental health services.

Increase mental and behavioral prevention services.

Active Living Several community leaders said they would build an indoor sports and wellness center.

Build an outdoor community center with a challenge course.

Healthy Eating Increase access to healthy local food..

Economy Stimulate tourism in the area by making Tenney Mountain Ski Area a year-round resort with a golf course and hotel.

Community/Activity Center Start a free indoor family activities center.

Implement more options for after school programming.

Build a new facility for Tapply Thompson Community Center that includes a pool

and exercise room.

Make a large events venue.

Housing Build a housing option for homeless veterans.

Implement more transitional living programs.

Build more affordable housing.

Outdoor Spaces Build playgrounds for every community.

Improve parks.

Charitable Trusts &

Microcredit

Put funding in a trust for long-term planning.

Provide microcredit loans or grants to local families in need.

Create “love accounts” or endowments for un-insured residents.

Create a dental health insurance pool.

Early Learning Ensure funding for HeadStart.

Open a full day learning center and extended day kindergarten program.

Transportation Implement a transportation model like Center Harbor.

Health Information Exchange Two community leaders want to invest in a health information exchange.

Dental Care Several community leaders want to improve dental care and increase capacity.

Create a dental health insurance pool for uninsured.

Figure 38.



Endnotes

1 America’s Health Rankings, United Health Foundation; 2010. 2 Institute of Medicine Committee on Using Performance Monitoring to Improve Community Health, Improving Health in the Community, A Role for Performance Monitoring. 1997, Washington, DC: National Academy Press. 3 Evans, R., M. Barer, and T. Marmor, Why Are Some People Healthy and Others Not? 1994, New York: Aldine De Gruyter.

4 2005-2009 American Community Survey 5-year Estimates


6 US Census 2000

7 US Census 2010, SF1

8 Bureau of Labor Statistics, Local Area Unemployment Statistics Data, Updated 2011: http://www.ers.usda.gov/data/unemployment/RDList2.asp?ST=NH

9 2005-2009 American Community Survey 5-year Estimates, (90% margin of error)

10 North Country Council-Transport Central, Nelson/Nygaard consulting associates. Transit Feasibility Study: Draft Final Report, September 2010.

11 NH Division of Public Health Services. 2011 Snapshot of New Hampshire’s Public Health Regions, Counties, and the Cities of Manchester and Nashua. Note: Data represents the Greater Plymouth Public Health Region geography.

12 Behavioral Risk Surveillance Survey, 2004-2008 Note: Data represents Grafton County geography. 13 NH Division of Public Health Services. 2011 Snapshot of New Hampshire’s Public Health Regions, Counties, and the Cities of Manchester and Nashua. Note: Data represents the Greater Plymouth Public Health Region geography.

14 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), Greater Plymouth Public Health Region Data Profile, 2008-2009.



17 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, Division of Vital Records Administration, [2006-2007-2008].

18 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, Division of Vital Records Administration, [2006-2007-2008]. 19 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, Division of Vital Records Administration, [2003-2004-2005-2006-2007]. 20 NH Division of Public Health Services. 2011 New Hampshire State Health Profile

21 United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Compressed Mortality File (CMF) on CDC WONDER On-line Database, 2007


23 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), Dartmouth Medical School. New Hampshire State Cancer Registry, 1997-2007.





26 ibid

27 McCormick MC. The contribution of low birth weight to infant mortality and childhood morbidity. New England Journal of Medicine. 1985; 312(2): 82-90.


29 Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Preventing Smoking and Exposure to Secondhand Smoke Before, During, And After Pregnancy. October 2, 2007; http://www.cdc.gov/NCCdphp/publications/factsheets/Prevention/smoking.htm.

30 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, Division of Vital Records Administration, [2008].

31 CDC MMWR. Trends in Smoking Before, During and After Pregnancy—Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 31 Sites, 2000-2005, http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5804a1.htm, [2005]

32 NH Division of Public Health Services. 2011 New Hampshire State Health Profile 33 NH Division of Vital Records Administration Birth Certificate Data, 2008. Accessed from NHHealthWRQS 10/2011. Note: Data set includes the town of Canaan, which is not part of the service area and is missing the towns of Waterville Valley and Wentworth. 34 NH Division of Public Health Services. 2011 New Hampshire State Health Profile


36 Centers for Disease Control. National Center for Health Statistics; http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_16.pdf

37 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, Division of Vital Records Administration, [2008].

38 Institute of Medicine. The Future of the Public’s Health in the 21st Century, Washington, D.C.: National Academies Press, 2002.

39 Centers for Disease Control, National Childhood Blood Level Surveillance Data (2007); http://www.cdc.gov/nceh/lead/data/national.htm

40 Centers for Disease Control and Prevention. Blood Lead Levels--- United States, 1999-2002. MMWR Weekly. Vol 54; 2005: 513-516.



43 New Hampshire Immunization Program, Grafton County 4:3:1:3:3:1:4 Rates, 2010

44 US, National Immunization Survey, Q3/2008-Q2/2009 Note: US rate confidence interval equals +/- 1.2 and NH rate equals +/- 5.9.

45 New Hampshire Department of Health and Human Services, Division of Public Health Services. New Hampshire State Health Profile, 2011.


47 NH 2008-2009 Third Grade Healthy Smiles-Healthy Growth Survey



48 Obesity Prevention Program, NH Department of Health and Human Services, Division of Public Health Services. Dec 2010 Childhood Obesity in New Hampshire, 2008-2009

49 Martin TA, White C, Van Dole K. The New Hampshire Health Assessment Project. NH Dept. of Education, 2003.

50 Martin TA, Helping NH’s Children Become Their Physical Best. NH Medical Society Annual Meeting November 2004.

51 New Hampshire Department of Health and Human Services Division of Public Health Services, Bureau of Population Health and Community Services Obesity Prevention Program. New Hampshire Obesity Data Book, 2010.

52 Child and Adolescent Health Measurement Initiative. 2007 National Survey of Children's Health, Data Resource Center for Child and Adolescent Health website. Retrieved 11.24010 from www.nschdata.org

53 Eaton D, Brener N, Kann LK. Associations of health risk behaviors with school absenteeism. Does having permission for absence make a difference? Journal of School Health. 2008; 72(4): 223-229.



56 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, Division of Vital Records Administration Death Certificate Records, [2004-2007].

57 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, NH Hospital Discharge Data Collection System, 2003-2007. 58 NH Division of Public Health Services. 2011 Snapshot of New Hampshire’s Public Health Regions, Counties, and the Cities of Manchester and Nashua. Note: Data represents the Greater Plymouth Public Health Region geography.

59 New Hampshire Department of Health and Human Services Division of Public Health Services, Bureau of Population Health and Community Services Obesity Prevention Program. New Hampshire Obesity Data Book, 2010.


61 NH Dvision of Vital Records Administration Death Certificate Data, 05-07 62 HRSA, Bureau of Primary Health Care, 2010

63 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, NH Hospital Discharge Data Collection System, 2010




67 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, NH Hospital Discharge Data Collection System, 2006.


69 Behavioral Risk Surveillance Survey, 2008.

70 National Survey on Drug Use & Health, 2004-2006.


72 Healthy NH Leadership Council.




74 National Survey on Drug Use & Health, 2004-2006.

75 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, NH Hospital Discharge Data Collection System, 2003-2007.


77 CDC Injury Center Media Relations. CDC Study Finds Seat Belt Use Up to 86 Percent Nationally, 4 Jan 2011.



80 CDC Injury Center Media Relations. CDC Study Finds Seat Belt Use Up to 86 Percent Nationally, 4 Jan 2011.

81 North Country Council-Transport Central, Nelson/Nygaard consulting associates. Transit Feasibility Study: Draft Final Report, September 2010.

82 A Picture of Subsidized Housing, 2008.

83 New Hampshire Department of Health and Human Services, Bureau of Homeless and Housing Services. 2011 Point-in-Time Count January 26, 2011, 2011.

Appendix I Community Survey Results

CNHHP Central New Hampshire Health Partnership

PARTNERS Communities for Alcohol and Drug-Free Youth Community Action Program, Belknap-Merrimack Counties, Inc. Genesis Behavioral Health

Mid-State Health Center Newfound Area Nursing Association Pemi-Baker Home Health And Hospice Plymouth Pediatrics and Adolescent Medicine Plymouth Regional Clinic Speare Memorial Hospital Whole Village Family Resource Center

www.cnhhp.org

COMMUNITY HEALTH NEEDS SURVEY

EARN $$ FOR A LOCAL CHARITY!

Dear Community Member:

The Central NH Health Partnership is working to collect information about the health of your community and we want to hear from YOU.

For each local resident that completes the survey, the Central NH Health Partnership will donate $2 to a local charity in need!

Please take 5‐10 minutes to give us your thoughts and opinions. The survey is completely anonymous. You will not be asked for your name or contact information.

Your opinions on how we can build a healthier community are important!

Thank you very much for your time.

If you have any questions on this survey please call 573‐3341. A summary report of the survey results will be locally available.

Thank you again for your help.

CNHHP Partners

“Your community” can mean different things to different people. For the purpose of this survey, your community can be as big as the Greater Plymouth & Newfound area or as small as your town. Answer the survey questions by thinking about the area you see as “your community”.

APPENDIX I


CNHHP 2 of 62 Central New Hampshire Health Partnership

APPENDIX I ALL SURVEY RESPONSE FREQUENCIES (n=600 completed responses)

11.. What do you think are the most pressing health issues in your community today?

(Check up to 5)

5500..22%% Access to dental health care 3344..11%% Youth alcohol & drug use

3344..44%% Access to mental health care 3377..55%% Alcohol & drug use

3322..44%% Access to primary health care 2255..33%% Smoking/tobacco use

88..55%% Access to specialty services Please specify: _____________________

1133..77%% Cancer

3399..22%% Access to enough health insurance 44..22%% Asthma

1188..00%% Health care for seniors 22..00%% HIV/AIDS

3333..77%% Mental i l lness (depression, anxiety, etc.)

55..88%% Sexually transmitted diseases

77..88%% Alzheimer’s 11..55%% Other infectious diseases

1111..77%% High blood pressure/heart disease 44..11%% Prenatal care

1122..99%% Diabetes 88..66%% Unplanned pregnancy

3344..77%% Poor nutrit ion/unhealthy food 1155..33%% Teen pregnancy

3355..99%% Not enough exercise

66..99%% Other Please specify: ___________________

TOP 10 Most Pressing Health Issues 1. Access to dental health care 2. Access to enough health insurance 3. Alcohol & drug use 4. Not enough exercise 5. Poor nutrition/unhealthy food 6. Access to mental health care 7. Youth alcohol & drug use 8. Mental illness 9. Access to primary health care 10. Smoking/tobacco use

5500..22%%

3399..22%%

3377..55%%

3355..99%%

3344..77%%

3344..44%%

3344..11%%

3333..77%%

3322..44%%

2255..33%%

Most Common Open‐ended Responses to “Access to Specialty Services” 1. More local service options in general (1.5%) 2. Mental health services (1.0%) 3. Transportation (0.7%)



APPENDIX I

22..

What do you think are the most pressing safety issues in your community today?

(Check up to 5)

6644..11%% People under the influence of alcohol or drugs

1155..88%%

Discrimination based on l i festyle choices or race

2211..33%% Crime 1111..77%% Identity theft

2211..88%% Youth crime 2255..44%% Being prepared for an emergency

4499..00%% Child abuse or neglect

88..22%% Safety at public places (parks, streets, etc.)

1155..55%% Elder abuse 1133..66%% School violence

1166..00%% Rape and sexual assault 4499..88%% Bullying/cyber‐bullying

5500..33%% Domestic violence or partner abuse


TOP 7 Most Pressing Safety Issues

1. People under the influence of alcohol or drugs 64.1% 2. Domestic violence or partner abuse 50.3% 3. Bullying/cyber‐bullying 49.8% 4. Child abuse or neglect 49.0% 5. Being prepared for an emergency 25.4% 6. Youth Crime 21.8% 7. Crime 21.3%

Most Common “Other” responses for most pressing safety issues

1. Driving/traffic safety (1.5%) 2. Not enough activities for youth (0.5%)



APPENDIX I

3. What services or resources should we focus on improving to support a healthy community? (Check up to 5)

5500..77%% Public transportation 2233..33%% Services for persons with disabil it ies

5555..88%% Job opportunities 2222..11%% Substance abuse recovery programs

2266..55%% Job training 4499..88%% Access to affordable housing

2222..33%% Adult education & learning opportunities

3311..33%% Access to affordable food

2288..99%% Parenting support 99..77%% Access to affordable clothing

2255..22%% Quality child care 1111..44%% Clean air and water

3366..11%% Youth programs and support 88..22%% Sports and event opportunities

2211..66%% Education in the public schools 1100..22%% Arts and cultural events

2266..77%% Support for older adults


TOP 9 Services or Resources to Focus on Improving to Support a Healthy Community

1. Job opportunities 55.8% 2. Public transportation 50.7% 3. Access to affordable housing 49.8% 4. Youth programs and support 36.1% 5. Access to affordable food 31.3% 6. Parenting support 28.9% 7. Support for older adults 26.7% 8. Job training 26.5% 9. Quality child care 25.2%

Most Common “Other” Responses for Services or Resources to Support a Healthy Community

1. Access to affordable health care 1.3% 2. Domestic Violence Education/Support 1.2% 3. Mental Health Support/Resources 0.5% 4. Poverty Reduction 0.5% 5. Jobs 0.5%



APPENDIX I

4. In the past year, have you or someone in your family had difficulty getting the services you needed?

4444..55%% Yes (continue below) 5555..55%% No (skip to question 5 on next page)

4b. If yes, which services did you or your family have difficulty accessing?(Check all that apply; percentages below are of all respondents; n=600)

1188..00%% Primary health care

99..33%% Social/human service agencies

77..22%% Specialty health care Please specify: ___________________

66..22%%

Drug & alcohol treatment/recovery services

66..22%% Dental care for children 55..88%% In‐home support services

2233..55%% Dental care for adults

33..00%% Long‐term care (assisted l iving or nursing home care)

1100..55%% Mental health


66..55%% Emergency health care

Top 5 Services with Experience of Access Difficulties

1. Dental care for adults 23.5% 2. Primary health care 18.0% 3. Mental health 10.5% 4. Social/human service agencies 9.3% 5. Specialty health care 7.2%

Most Common Open‐ended Responses to difficulty accessing “Specialty health care”

1. Orthopedics 0.5% 2. Diabetes 0.3% 3. Dental 0.3%

Other Services Commonly Mentioned with respect to access difficulty

1. Transportation 0.8% 2. Financial/Eligibi l ity Assistance 0.7%



APPENDIX I

4c. If yes to #4, why was it difficult to get the services you needed?(Check all that apply; percentages below are of all respondents; n=600))

1100..55%% Did not know where to go to get services

2211..88%% Had no health insurance

55..33%% Did not understand how to get the service

77..00%%

Service was not accepting new cl ients/patients

44..77%% Office was not open when I could go 44..22%% I was turned away

1133..00%% Service I needed was not available 2244..77%% Could not afford to pay

99..77%% Had no way to get there 33..33%% Needed help with paperwork

88..00%% Waiting time to receive the services was too long

22..55%% Misunderstanding with staff

44..55%% Had no one to watch my child 00..22%% Language/cultural barrier

1122..88%% I was not eligible for services

33..33%% Did not want people to know that I need the service


TOP 8 Reasons for difficulty getting services (percentages are of all respondents) 1. Could not afford to pay 24.7% 2. Had no health insurance 21.8% 3. Service I needed was not available 13.0% 4. I was not eligible for services 12.8% 5. Did not know where to get services 10.5% 6. Had no way to get there 9.7% 7. Waiting time to receive the services was too long 8.0% 8. Service was not accepting new clients/patients 7.0% Other Reasons Commonly Mentioned for access difficulty 1. Coverage/eligibil ity l imitations 0.8% 2. No dental insurance 0.7% 3. Travel/distance 0.5%



APPENDIX I 5. Which of the following programs or services would you or your family use if it

was more available in your community? (Check all that apply)

2288..55%% After‐school activities for youth 4499..22%% Fitness/exercise program

1188..55%% Childcare 3300..99%% Nutrition/cooking program

77..44%% Adult daycare 3344..22%% Weight loss program

1133..55%% Parenting support groups 1133..33%% Health education

1166..66%% Family counseling

55..00%% Lesbian, gay, trans‐gender and bisexual support services

99..66%% Caregiver support 66..55%% Diabetes support group

1133..77%% Education workshops for parents 2211..66%% Mental health counseling

2244..88%% Adult education 1111..11%% Drug and alcohol treatment

2277..22%% Job training

99..44%% Drug and alcohol prevention activit ies

1122..88%% Information and referral 1166..66%% Stop smoking program

4411..22%% Stress reduction and relaxation classes

77..22%% Medical services Please specify: ___________________

1177..99%% Community gardening 3355..99%% Public transportation


TOP 6 Programs or Services respondents would use if more available 1. Fitness/exercise program 49.2% 2. Stress reduction and relaxation classes 41.2% 3. Public Transportation 35.9% 4. Weight loss program 34.2% 5. Nutrition/cooking program 30.9% 6. After‐school activities for youth 28.5% Most Common Open‐ended responses for “Medical Services” 1. Dental Care 0.7% 2. Affordable Health Care 0.5% 3. Primary Care 0.5% 4. Specialists, in general 0.5% "Other" Commonly mentioned services respondents would use if more available (open‐ended responses to question 5) 1. Dental Care 0.5% 2. Affordable programs/services 0.5% 3. Transportation 0.3%



APPENDIX I

6. What do you think is the best thing about l iving in your community?

472 total comments were received. The most common theme (approximately 25% of respondents) regarding the best thing about l iving in their community is:

FAMILY, FRIENDS & NEIGHBORS; Helpful People, Sense of Community Connections and Support

See Page 23 for a complete l ist ing of comments organized by major theme

7. What do you think is the most difficult thing about l iving in your community?

477 total comments were received. The most common theme (approximately 18% of respondents) regarding the most diff icult thing about l iving in their community is:

Lack of Transportation/Public Transportation


8. If you could change one thing that you believe would contribute to better health in your community, what would you change?

414 total comments were received. The most common theme (approximately 11% of respondents) regarding the one thing they would change to contribute to better health in the community is:

HEALTHIER EATING/ACTIVE LIVING


The fol lowing questions will help us to better understand the characteristics of your community. This information will not be used to identify you in any way.

9. What is your age?

11..44%% 18‐19 3300..33%% 50‐64

88..33%% 20‐24 99..99%% 65‐74

1188..22%% 25‐34 55..88%% 75 and older

2266..00%% 35‐49 Skipped question=7.6%

10. What is your gender?

2244..33%% Male 7755..77%% Female

Skipped question=9.5%



APPENDIX I

11. About how many years have you l ive in the Greater Plymouth or Newfound area?

Average number of years respondents have l ived in the region = 20.9 years Median number of years = 18 years Range: minimum of less than 1 month; maximum of 114 years 26.3% of respondents have l ived in the region for 8 years or less 24.7% of respondents have l ived in the region from 9 to 18 years 27.1% of respondents have l ived in the region from 19 to 30 years 21.9% of respondents have l ived in the region for more than 30 years

12. What town do you l ive in now?

55..11%% Alexandria 11..55%% Lincoln

77..11%% Ashland 22..77%% New Hampton

33..66%% Bridgewater 00..22%% Orange

1122..99%% Bristol 2233..11%% Plymouth

1100..44%% Campton 55..66%% Rumney

11..33%% Danbury 66..22%% Thornton

00..44%% Dorchester 00..99%% Warren

00..22%% Ellsworth 00..55%% Watervil le Valley

00..55%% Grafton 22..66%% Wentworth

22..22%% Groton 11..11%% Woodstock

22..22%% Hebron

33..88%% Other Please specify: __________________

55..88%% Holderness

Other towns mentioned inc lude: Frankl in (0 .7%) Hi l l (0 .5%) Sandwich (0 .3%) Canaan (0 .3%) Andover (0 .2%) Center Harbor (0 .2%) Gi l ford (0 .2%) Laconia (0 .2%) Meredith (0 .2%) Ossipee (0.2%) Piermont (0 .2%) Ti l ton (0.2%)



APPENDIX I For questions 13 & 14, a household is a group of people sharing a home and any income earned with each other.

13. Approximately, what is your annual household income?

1166..11%% Less than $10,000 1188..11%% $50,000‐ $74,000

1199..66%% $10,000‐ $25,000 1111..99%% $75,000‐ $100,000

2266..33%% $25,000‐ $49,000 88..00%% More than $100,000

Skipped question=14.3%

14. How many people are part of your household?

Average number of people in the household = 2.9 Median household size = 3 people Range: minimum of 1 person; maximum of 13 people 14.6% of respondents have 1 person in their household 33.9% of respondents have 2 people in their household 21.2% of respondents have 3 people in their household 18.3% of respondents have 4 people in their household 12.0% of respondents have more than 4 people in their household

҉ Thank you ҉



APPENDIX I

Open‐Ended Responses to "access to specialty services" as a most pressing health issue (Question 1)

Category Response

More Local Service Options 1.5%

always have to travel

MD's ‐ localize ‐ travel less

Need closer MD's

Need local

need locally

No local MD's, transportation.

Nothing local

Oftentimes i f a "specialty service" is recommended there may be only one choice for the family in the area, or none at all, within a close driving distance. This is especially true for mental health services including the often recommended‐ therapy. Families frequently drive to DHMC, Manchester, Laconia, Concord, or even Boston for evaluations but continued care is very hard to come by in the local area.

If there are specialists (ENT, OB‐GYN, cardiology, etc.. .) in the community the choices are l imited and the quality of the faci l it ies is l imited.

Mental Health Services 1.0%

Counseling

Counseling

Infant Mental Health Services

mental health and dental

Oftentimes i f a "specialty service" is recommended there may be only one choice for the family in the area, or none at all, within a close driving distance. This is especially true for mental health services including the often recommended‐ therapy. Families frequently drive to DHMC, Manchester, Laconia, Concord, or even Boston for evaluations but continued care is very hard to come by in the local area.

Wrap around services for children with mental i l lness and history of abuse but sti l l l ives with parents.

Transportation 0.7%

lack of transportation

No local MD's, transportation .

Shuttle bus service for seniors and special needs patients (wheelchair‐bound citizens) and those who cannot drive.

This is a rural area, and access to any healthcare services can be a challenge due to lack of transportation for the elderly,



APPENDIX I mentally i l l and poor residents within the community.

Cardiology 0.5%

Cardiology , gastrointerology

cardiology , pulmonologist, podiatrist, Decent Orthopedics that I would be will ing to go to. Female Physicians, vascular surgeons‐ and even i f they were here‐ there is no type of this surgery here.

If there are specialists (ENT, OB‐GYN, cardiology , etc.. .) in the community the choices are l imited and the quality of the faci l it ies is l imited.

Dermatology 0.3%

Dermatology

Dermatology & other

Orthopedics 0.3%

cardiology, pulmonologist, podiatrist, Decent Orthopedics that I would be will ing to go to. Female Physicians, vascular surgeons‐ and even i f they were here‐ there is no type of this surgery here.

Ortho

Pulmonology 0.3%

cardiology, pulmonologist, podiatrist, Decent Orthopedics that I would be will ing to go to. Female Physicians, vascular surgeons‐ and even i f they were here‐ there is no type of this surgery here.

Pulmonary

Uninsured/low income services 0.3%

all for the un or under insured

community care does not cover special doctors l ike orthopedic, pain clinic, or physical therapy.

Other Specialties

Cardiology, gastrointerology

cardiology, pulmonologist, podiatrist , Decent Orthopedics that I would be will ing to go to. Female Physicians, vascular surgeons‐ and even i f they were here‐ their is no type of this surgery here.

Head injury group

Home care My physical therapy was cut off, I appealed but was denied. I don't even f inish f irst phase of therapy so i t wil l hurt my condit ion extremely. Specialty services are al l outside.

Optometrist

Orthodontics

special ists

Theraputic services



APPENDIX I Urology

Autism

Other any service not covered by PCP

Concord, Dartmouth

chinese herbal ist

Chronic i l lnesses and condit ions

Other Most Pressing Health Issues (open‐ended responses on Question 1)

Domestic Violence 1.2%

Domestic Violence (5 mentions)

domestic violence, stalk ing issues

Health issues related to violence in famil ies, DV/SA/CA

Disabil ity Issues 0.8%

Advocacy for disabi l i ty.

doctors need to know about laws and requirements about disabi l i ty

MD's need to know about laws & requirements about disabi l i ty.

I f you are trying to get on disabi l i ty, disabi l ity requests mds. in this are nurse practit ioners aren't our pcps.

Nurse practit ioners be = ? under disabi l i ty law.

Obesity 0.7%

Obesity (4 mentions)

Dental Care 0.5%

affordable dental health care

Access to dental insurance for those who don't qual ity for healthy kids.

dental services

Insurance/Affordable Care 0.5%

Development of affordable health care for everyone.

insurance cutoff ‐only al lowed so many vis its

Not enough insurance coverage.

Youth Activities 0.3%

Not enough activ it ies for chi ldren during summer.

Youth activ it ies

Transportation 0.3%

Transportat ion

Transportat ion to health care

Other Abil i ty to care for s imple condit ions and i l lnesses.

At this point I 've had no trouble obtaining assistance in areas of health issues



APPENDIX I Birth control ‐ family planning for al l .

Head traumas

Health care for homeless

health care options for healthy adults

Lymes Disease

MD's, cl inics. Should be unbrel lered with al l mass needed specialty and regular. Not enough units for therapy.

New patient for doctors.

No parking place for parking on walk.

No sense of personal responsibi l i ty.

Nursing Home

Pediatr ic ians need to be educated and wil l ing to refer chi ldren suspected to have neurological disorders, such as sensory processing disorder.

School lunch sucks. No more phys. ed!! What are they crazy?

Too many abort ions

Other Most Pressing Safety Issues (open‐ended responses to Question 2)

Driving Safety 1.5%

Aggressive driving

auto safety i .e. unsafe drivers

Cel l phones

Drivers who don't pay attention

Driving & cel l phones/texting

Driving badly

Driving while text ing and cel l phone use

Drunk driving

Insuff ic ient enforcement of traff ic laws, speeding in town.

Not enough youth programs 0.5%

Not enough programs for kids.

Not enough recreational activ it ies for chi ldren 10 to 18 years old.

Nothing in area for chi ldren unless you have $.

Mental Health 0.3%

mental health

mental health patients

Age Discrimination 0.3%

age discr imination

Age‐ ism

Other Are there emergency plans in place for BiPap and C‐Pap users? Also O2 users?

at this t ime i feel that these issues are well in check

Babies unsafe in the womb from abortion.

cyber crimes

Elderly at home when more assistance needed ‐ transportat ion,



APPENDIX I more assisted l iv ing or more insurance coverage for home care agencies to go into homes.

Insurance

Lack of vis ion for a future based in mutual respect for our neighbors, lack of education to understand we are creating al l of our issues confronting us.

mail theft

Neglect of our elderly by their famil ies of origin

Non ‐tradit ional & dysfunctional homes; absent parents.

Not enough sexual health classes for the youth

Not enough s idewalks and no paved walking and biking paths along roadways

People steal ing in apartments al l over.

Pol ice hide their heads, not admitt ing i t (drugs).

Proper l iv ing condit ions due to poverty.

War on Drugs, Foreign Wars, Economy

Other Services or Resources to Support a Healthy Community (open‐ended responses to Question 3)

Access to affordable health care 1.3%

Access to affordable health care

Access to Insurance or Alternatives up front.

Affordable access to whatever health care people need.

Affordable health care

cheaper health care system

Free healthcare for low income famil ies.

Health Care

Income l imit is low; people with higher incomes that pay for their health can't get help.

Domestic Violence Education/Support 1.2%

Community education on DV/SA/CA

domestic violence support

DV services

Increased capacity for DV/SV cris is services

increasing capacity of DV/SA/Elder Abuse/Bul ly ing cris is services

Expanded DV/SA Services

More education to communit ies about the impact of Domestic Violence and Sexual assault and how to hold batterer 's accountable in DV and rapists accountable in Sexual assault cases.

Mental Health depression hotl ine service

Mental health, access to care and care.



APPENDIX I Support/Resources 0.5%

Support for chi ldren with a history of mental i l lness and abuse who need government support, but st i l l l ives with parents

Poverty Reduction 0.5%

Poverty Reduction

Reduction of Poverty

Money avai labi l i ty to low income.

Jobs 0.5%

Jobs affordable food and housing and publ ic transpo are huge problem areas around this area

Jobs that pay a decent salary.

Special ized job avai labi l i ty

Housing Assistance 0.3%

More answers to subsidy housing.

Programs needed so people that are extremely low income can own a house.

Recreational resources 0.3%

Outdoor activ it ies (walking and bike paths).

we need rol ler skating r inks and bowling and parks for everybody and indoor and outdoor pools

Healthy Food 0.3%

affordable healthy food

nutrit ion/healthy food & exercise

Autism Awareness/Education 0.3%

Autism

That special education teachers and other school staff are educated in neurological disorders such as sensory processing disorder and autism spectum disorders.

Other affordable chi ld care

Dental care especial ly as well as transportat ion.

Help with disabi l i ty court.

individual/s ingle person services‐ human services dept. welfare ‐ state f inancial assistance, f inancial security

Intergenerational outreach programs would benefit both elders and youth.

more avai labi l i ty to lower income

More review and re ‐determination of disabi l i ty claims

Pro ‐ l i fe pregnancy/resource centers.

Something in the Bristol area that wil l be good for older kids & also places that wil l do groups for anxiety.

Vocational training H.S.

We have no need for any of these programs. There are only 2 adults here.



APPENDIX I Specific specialty health care mentioned with respect to access difficulty (question 4b)

Orthopedics 0.5%

fol low ups for orthopaedics, labs, x ‐ray and other diagnostic tests, fol low up for gastrointest ional disorders

ortheopedics

Orthopedics

Diabetes 0.3%

diabetes

Diabetes, dental

Dental 0.3%

Diabetes, dental

Dentures

Other A family member is a recent amputee with spina bif ida. Doesn't drive. There are no special ists in the area which means over an hour drive for every doctor appointment. For a low income non driver i t 's very hard for her to get to doctor’s appointment due to price of gas and lack of transportat ion

A need for the diagnosing, treatment, and education of neurological disorders such as sensory processing disorder, and autism spectrum disorders.

affordable eye care glasses

al l services above

alternative health care

back pain and expert doctors

cardiology

Chronic i l lnesses, home care

Chronic, so i f I go to ER for acute they won't treat me. Lied to by agencies so I lost disabi l i ty.

concussion

Dermatology

Food

Gynecology services. Would prefer a female DR/ARNP

Have to travel 100 miles with a bad back.

I am sole caregiver for my husband and need help with blood pressure and pulse monitoring

Insurance ran out.

lung/alphal

Lyme Disease

Maternity Care

Mental health drugs, emergency health care for kidneys. I know of 2 people who needed help and couldn't get what was needed and both died.



APPENDIX I No local MD's

Not enough rehabs accessible to those with l i tt le to no money.

pain cl inic, physical therapy, with no insurance

PCP ‐ Nurse Practit ioners

Pediatr ics

Pediatr ic occupational therapy

Physical therapy

Specialty doctors

substance abuse programs

Too far to travel

transportat ion

urologist

UTI problems

"Other" services with access difficulty (open‐ended responses to question 4b)

Transportation 0.8%

Transportat ion

transportat ion to get to these locations (no publ ic transportat ion or taxis)

transportat ion to receive health care

in town service for people without a car

Help with disabi l i ty, cleaning, driving, etc.

Financial/Eligibil ity Assistance 0.7%

Disabil i ty needs to be recognized, most people that have i t don't need i t and to get i t you have to jump through hoops i f I could jump.

f inancial ly l imited. went for help in plymouth 3x $15 gas or hannaford card and has told they cant help me forever. i f i need help i ts hard enough to go because you feel embarassed

Food stamps

Help with SSI , f inances without feel ing that you're an id iot.

Other Affordable chi ldcare

As a nurse I see mainly non ‐ insured have diff iculty.

Autism

cancer support groups

Community people to help low income. Businesses need to kick in $ to hand out without red tap. Housing, low income people are real people, have no chance to own a home. Support services used only for severly injured. Depressed and chronic back problems, people needed to help.

deprivation of character moral support

Durable medical equipment

Free things for low income help ‐ housing, food, clothing.

Getting MD's for al l medical when you have state insurance.



APPENDIX I healthcare by a physician that wasn't in a "fast food" type of practice l ike Midstate

Healthcare we can afford.

Housing

insurance

Limited income ‐ no insurance

List of services for the elderly and low income

New patient for doctor ‐ medicare only insurance.

No way to get home i f no support system.

Out of area/insurance denial .

Physical therapy & massage

Vis ion care + Glasses for adults

Without dental insurance.

"Other" reasons for difficulty accessing services (open‐ended responses to question 4c) Coverage/eligibil ity l imitations 0.8%

Legal ly bl ind, stated I did not qual i fy for service

No dental insurance or medical coverage for massage

My Health Care insurance company did not have any local providers.

Insurance l imits

Insurance would not cover my diagnosis .

No dental insurance 0.7%

No dental insurance or medical coverage for massage

No dental insurance

Had no dental insurance

No dental health insurance

Travel/distance 0.5%

Distance was a problem.

distance to services

too far to travel

Other Autism

No money to pay.

Medicare only insurance, would not accept new patients.

Not local (good ones)

Too much money

People explain but they don't care and people lose law cases.

Lost disabi l i ty because I worked for State of Mass. doing special ized foster care, had to s ign waiver that I would not work outside home. For 6 years income not counted.

Needed case management and support ive services.

Most in am, can't go in pm due to health reasons.

didn't diagnose problem correct ly



APPENDIX I i cal led for a vis it ing nurse but recieved no answer

Litt leton, NH Social Security off ice NEVER answer the phone.

Insurance

unable to f ind another provider interested in a healthy person

insuff ic ient subst itute for darvace T curing pains

we had run around with our 19 year old ‐ trying to get mental help for her! we had the run around, everyone would point to another person ‐ now she is 23, st i l l mental ly i l l , homeless and there is no place for her to get long term help, she is in and out of place with strangers, she has been assigned a guardian

Sorry, have to say al l of the above.

They do not count al l of my bil ls for food stamps ‐ not fa ir .

No insurance

became homeless and was told I did not qual i fy for f inancial assistance. lost my home & family due to a stalking issue

Because the services are more money than we can afford.

Was denied health insurance coverage by current insurance provider, but make too much money to qual i fy for need based programs, spend the f i rst 12 weeks f ighting with insurance companies in order to recieve coverage. Was more of a health insurance/state regulat ion problem rather than community coverage problem

l imited number of mental health counselors within a reasonable distance

I have 2 chi ldren which makes me a relat ive caregiver. One of these chi ldren has special needs & during the summer i t is diff icult to keep her occupied

Chi ld was misdiagnosed with ADHD for 3 years from pediatr ic ian.

Medical Services respondents would use i f more available (open‐ended responses on Question 5)

Dental Services 0.7%

Dental

Doctor, dentist , pain management, physical therapy for a bad back

Health & dental care .

medical/dental primary adult doctor

Affordable Health Care 0.5%

Affordable, low cost, hassle ‐free health care. There is a "low cost/free" cl inic in the area. Once a week for 2 hrs. Often, i t is too crowded and people can’t be f i t in.

for uninsured

Nobody should be denied because of f inancing.

Primary primary



APPENDIX I Care 0.5%

medical/dental primary adult doctor

basic pcp checkups without insurance and physical therapy routine appointments for chronic health i ssues

Specialists, in general 0.5%

Special ists

Specialty needs to be closer

special ists

Cardiologist 0.3%

Cardiologist , local durable medical equipment and in home services.

Regular heart special ist

Mental Health Services 0.3%

Mental health, general peer support especial ly i f stressed out.

Therapy/counsel ing

Other affordable hearing aide, eye glasses

cl inic in town

Dermatology, Endocrinology

doctor expert in orthopedics of the spine

ER, doctors off ice

Insurance didn't cover.

insurance doesn't cover

Insurance doesn't pay and not affordable to go to people. Only goes so far. A lot of MD's past area that transportat ion wil l go.

Insurance doesn't pay.

MD's that know about disabi l i ty laws.

Need affordable Health Insurance Plans avai lable to al l ‐ no matter what your income or previous history

Need MD's that aren't covered by state.

Payment plan for dentures.

Rehab faci l i t ies, in ‐patient & out‐patient.

r ides for those unable to drive to dr. appt/ treatments

"Other" services respondents would use i f more available (open‐ended responses to question 5)

Dental Care 0.5%

Dental care

Affordable adult dental care

train/rai l service

Affordable programs/services 0.5%

$ wise, area is mostly under income, need good free programs. That treat us l ike f irst class cit izens.

All have to be avai lable, affordable for low income.

Reasonably priced tr ips for fun.

Transportation Rides to al l transportat ion.



APPENDIX I 0.3% Huge deal for younger demographic who cannot drive due to

visual impairment.

Other Advocates that are well informed and wil l fol low through.

Budgeting/Financial planning

cancer support group and counsel ing

Community counci l

Depression

disabi l i ty needs to help people not deny because of $ issues

Family Activit ies

help f inancial ly , food, clothes

Horseback r iding therapy

I go to what's avai lable for parenting support groups.

indoor pool for exercise, informational lecture/meeting on a variety of issues such as wine, women, and wisdom

Judges on disabi l i ty need to look at the paperwork and read i t , not just assume.

NANA is great.

People to come in to house free to clean or do things I can't do because of disabi l ity.

Publ ic education on Sensory Processing Disorder

We have no need for these programs, there are only 2 adults here.

Would have used many of these in the past.



APPENDIX I

Question 6: What do you think is the best thing about living in your community?

FAMILY, FRIENDS & NEIGHBORS; Helpful People, Sense of Community Support (25% of respondents)

Friends and family. People helping people. Small country living - pleasant neighbors. Good neighbors, EMS service and living in the country. Friends Friends, location. The people. Kindness, friendliness, congeniality of the people. Most people will help each other. Knowing many people in the area. Strong feeling of community. The people with an open heart and good soul. The people. People - setting - school (Plymouth/Ashland) Friendly people. It's support based. There are kids around for my daughter to play with. The support from people. Everyone tries to get you the help is you need it. Close community, everyone knows everyone. People are friendly. Everyone knows everyone else. Family closeness. Support system for school age daughter. It's a small town with good people. Involved caring people. The community. The people among the community are very caring and kind, and they do offer a decent program

for aid. The people who live here. The people are so friendly. Pleasant, neighborly That most everyone is connected on one or more ways to everyone else, a small community

such as ours is interconnected in a way that larger areas are not. It's a small community, so it’s comfortable and easy to get to know everyone. Pleasant atmosphere. Kind people.



APPENDIX I People are friendly and most try to help or understand what needs to be done. People help each other out. Friendly Strong community It's smallness - it's a close-knit community. Safe, friendly place to live. Our caring community who are devoted to making this the best place to live. The community awareness of its need to help others. Community is involved, many services available. Small and know everyone and are willing to help each other. Being a small town - knowing everyone. I like the neighborhood and my handsome neighbor. This is a caring community. People are friendly and try to help one another. It is small, lots of family and friends around. A sense of community with people willing to step forward to help others. The people People know you Close knit Community support, friendliness of outgoing neighbors. The closeness of the community, everyone knows one another. Small, everyone knows each other and helps. Everyone seems to know everyone and most of the people in this town will help as needed The friendliness of most people. Friends Friendly people People are friendly. The people, very friendly. The people are very nice and helpful. Small, caring community. Small community - generally people pull together to confront issues. It is a friendly community. The amount of people trying to better the community. Businesses are closely knitted together and are willing to help each other out. People work together. You do not get lost in the crowd. A sense of belonging Intact neighborhoods away from off-campus areas thrive, and people are still "neighborly. People Volunteers close knit, friendly The size of the community - when someone is in need people generally come together to help. Nice area and good community. Friendly atmosphere. people and friends are nice It is a community that cares



APPENDIX I The ability I have to support others Easy and possible to connect with others Community friendliness. Generally supportive environment Family Knowing other people Friendly atmosphere where everybody knows each other. Living in an area with like-minded people; those who care about an active, outdoor,

environmentally sound and community oriented lifestyle People Clean water, clean air and community support & interaction with people willing to be supportive

and helpful. Everyone is close together and are familiar with each other. pro-active people making a difference by volunteering My community is beautiful and they seem to care what is going on with people Small town community, knowing your neighbors people care about 1 another and respond when needed small close knit community everyone knows everyone friendly people, being a close knit community. great doctors knowing you can count on your neighbors close knit and caring the people- safe and clean it’s my home community spirit the friendliness of people and their support quality of life relative to safety, recreation, community values, clean air, natural beauty and safety

services, education the support i'm getting I have a better support system here. quieter communities closeness of the community people care about others more than in big cities friends, church, cultural events, rural atmosphere people work together sometimes That it is a small community; people seem to care more for their fellow neighbor. The small size. Everyone knows everyone else. The best thing is how it is "city like" but we still have hiking and plenty of health programs.

Everything is close knit, but we are all individuals. I love the location and the people in Plymouth. Ashland & Plymouth work together. It's small (Bristol) so I know a few people were like at the school etc. and it makes me feel

comfy, etc. Friends & family that help support people with disabilities.



APPENDIX I The sense of community. Mostly it is safe, clean and beautiful with a caring community. Knowing people Close knit - people who care Sharing small community w/people, getting to know small town and neighbors Being part of a community, rural environment Sense of community in rural area People, most of them are nice and helpful people care about each other; the outdoors Small community- people know each other and do their best to help everyone else out More of a tight knit community... families and friends overlap in many different parts of the

community to work together. The feeling of community small enough to know most people but getting large enough to support the growing community. The people...when someone is in need the community comes to their aid. I love living in a rural community because we know our neighbors and provide assistance to

each other in times of need. The close knit neighbors that support you in whatever your needs are. I enjoy living in a community where people know each other and support each other. Members of the community support one another in times of need. Community is small enough

so that you get to know people. Sense of community The community connections and the after school program opportunities in the Newfound area,

beauty, sense of community The people and the landscape. people willing to help others in need small-town knowledge and support of friends the people are so friendly here some people are helpful. engaged community Sense of commitment to change & supporting others. people truly care about one another It’s a quiet and caring community The quality of the people. Everyone is so willing to help out when there is a need. small community...people help others Support each other when support is needed. In a small town, people tend to take care of others, even as just a neighbor. We have clean air,

less traffic and noise pollution, and beautiful scenery too. The faith based community is strong. People don't hesitate to come together to address

common problems. There are caring people who try to make a difference People I think the people are the best thing in the area. The area is filled with truly wonderful people.



APPENDIX I Small community size, neighbors who look out for each other. Everyone knows each other. SMALL COMMUNITY, RURAL; Quiet (17% of respondents)

It's still small enough to be good for raising a family. It's a small town where everyone knows each other, friendly. Rural living. Quiet and not congested Everything is close by. The quiet rural area that I live in. Very quiet. Small sized community. It's quiet. Not too many people. It's not a bad little community, the people are ok. Alexandria is a quiet community and we love that there isn't a lot of people around us. That it is a small community. Small town Quiet neighborhood, decent people, small town. It is not the city. Ease of getting around. Rural - small town Size Small!! I like living in a small quiet town. Very rural I like the small town atmosphere. Being on my porch. Small communities networked with surrounding communities, outdoor opportunities. Familiarity Rural, minimal government involvement. Rural living. Peacefulness Rural character Getting to know the other residents due to small population. Natural beauty of the area. The stress free living. The scenery and the small town feeling. Living in country w/lakes and mountain. Small country town. Small town environment. Small and friendly. Small town It's quiet, people are very nice.



APPENDIX I Not too much traffic and commotion and green mountains, clean hikers. It's peaceful when college is gone. The peace and quiet It's rural. Rural setting, small town community, family-friendly "small town living" Small town feeling small town, college, beautiful setting Friendly. Removed from pressures of city life; e.g., kids wandering the malls at all hours; also , access to

good outdoor activities IF people would access them more Small town atmosphere Beautiful natural area. Slower pace of life. Rural character IT IS RURAL Being in a small town community with mountains and rivers Small town community. Fresh air, small community. Small it's quiet small towns, friendly people, the environment small, convenient town quiet rural, serenity, friends a non-city environment no crowds, little pollution quiet, for the most part safe. would not let my child go out at night though. small town,

beautiful, grew up here, resources - even if they don’t apply to me the people are very friendly, love the NH lifestyle, the beauty of our surroundings (mts, trees,

wildlife) rural nature small town nice quiet place, easy to relax peace and quiet - respect of a nobler person's privacy a nice, small, safe friendly country - we don’t have malls or busy, busy traffic. laid back, everyone

knows everyone small town mentality - bring pets to work; more relaxation at work and home Being in a rural area, less traffic It is smaller & people are friendly. Not congested - not too much fear of crime. The feeling of living in a small community where you know a lot of people, you see each day and

the comfort of feeling safe in your neighborhood. That it's not too busy and most people are friendly.



APPENDIX I It's quiet yet close enough to towns that have more going on. It's small and quiet. Fairly quiet Quite place Small town The quality of life because of the small town atmosphere. Rural Quiet compared to the city. Healthy environment - able to walk places, downtown has viable stores, services. Access to

outdoors. The rural nature of the setting - the availability of access to trails, streams, lakes & mountains Outdoor activities, lakes & mountains. Small friendly community. Small community Small size of community Small and quaint. Friendly The beautiful area and the kind people. The small size quiet and friendly small town feel location It's is rural, so there is a nice atmosphere, it isn't overly crowded, people are friendly. I live in an

area where I can breathe fresh air and get fresh water from several springs. I like small town rural community. little traffic, fresh air, quality of life quality of life Low volume traffic It is very quiet and peaceful small town feel PHYSICAL ENVIRONMENT, NATURE, OUTDOOR ACTIVITIES (16% of respondents)

Clean air. Less populated, clean environment, easy to get around (if you have a car!) It is a truly beautiful environment. Access to outdoor activities that are free or low cost. The location. Beautiful views, beaches, hiking trails, small community feeling. Surroundings Location - beautiful. Rural small town, lot of parks and trees and hiking. Not sure, the view. The area of our home and the town of Bristol right by the lake for my kids in the summer.



APPENDIX I Beauty of the area. The mountain, lakes and hiking trails. Environment - nature. Access to the outdoors, parks and hiking. Clean air and water. Low crime. Beauty of area. The mountain air! The Longue view. Beauty of NH View! NH mts. Fresh air, no traffic. Newfound Lake Newfound Lake especially state park for seniors. Natural environment, friendly people. Quiet, natural, beautiful. Clean air and water, open space, recreation opportunities, safe. Clean environment Environment The people and the mountains. Access to nature. Living in a rural environment. Access to nature and bike/walk path It's beautiful and a healthy environment & community. Lots to do and see. Environment It really is a beautiful area with Newfound Lake People, beauty of the mountains, lakes and rivers. Clean air Access to the outdoors & recreation. relatively small community, access to outdoor activities. Lake Newfound Environment Natural Environments~ lakes, rivers, trees, etc Community relationships The nature Location in terms of outdoor recreational activities Beautiful lake/mountain community which avails you to enjoy many wonderful outdoor

activities. It's a healthy environment. Wide open spaces. Fresh air - no big cities. Wilderness Outside It's a beautiful area. the beautiful land and nice people opportunities for outdoor activities the great outdoors fresh mountain air Fresh air, fresh water.



APPENDIX I The beauty of the mountains. Friendly environment, outdoor activity opportunities. The people and the beautiful landscape! Scenery The beautiful nature. The natural resources and outdoor activities readily available. Clean air, fresh water, good people. Clean air/water Easy access to beaches & mountains. The rural nature of the community. Provides a landscape of natural beauty where one can find

peace & quiet and solitude if one so chooses. Close to nature How beautiful it is. The beautiful environment Lakes and mountains environment - clean and safe Rural environment provides for easy access to fun, healthy, FREE, outdoor activities. Living so close to the Mountains, lakes; lower crime rate; small population-no traffic; outdoor

recreation accessible. The fresh air The natural environment lots of things to do outside Rural, and clean air open space nature Nice scenery, environment and outdoor recreation opportunities the scenery nature Outdoor resources Outdoor activities...hiking, biking, walking, kayaking, tubing Living in an a rural area which has so many natural resources fresh air and the mountain location The natural beauty, lakes, mountains. Country. Mountains and water. Friendly people. nature is close and an important concern to others it's rural with a lot of outdoor activities available. The beautiful surroundings Nature and peacefulness rail trails, access to trails and nature Our God given beautiful environment. Not congested, open, mountains & lakes, outdoors Nature....lakes mountains hiking swimming fishing etc The people can be pretty great too



APPENDIX I The activities available to do outside. Fresh air, clean environment The availability of amazing outdoor recreational opportunities. Living in nature ACCESS/PROXIMITY TO SERVICES, PROGRAMS; Cultural Activities (9% of respondents)

Access to services Stores are close by. I enjoy being close to a police and fire station. There is also great places to take walks. Everything is close by. Education and cultural opportunities available thru PSU and other groups Services and property tax benefits for the elderly and veterans. College programs - educational and recreational. Very good medical facilities & personnel.

Changing seasons. Excellent senior citizens center. It's pretty quiet, they do have food pantry and discount clothing. We have a senior center. Senior center Everything available, senior center, vans, meals on wheels, churches Easy access to health care, shopping, senior center, college. The senior center. Most everything is close by to where we live. Services available. Renewable energy conscious people. Farmers market, community garden, local foods,

Plymouth, PARE1, Silver Hall events, etc. Proximity to PSU and all it offers. Most things close by Community Center programs - the generous people - NANA - Community Service Cultural events - even though can't get there most of the time. Senior housing. Tapply Thompson Community Center The friendly atmosphere. A place for young people to go after school (TTCC) and after school

program. Great diversity and access to Plymouth State and Silver Arts. They have the Plymouth Regional Clinic but needs more days open. There are many options for low income homes. There are a lot of child activities local. The cultural center which PSU provides It’s walkable and we do have many youth programs and services for the elderly. Access to medical facilities Small-town atmosphere but still close to services Resources and referrals available to those who ask. people are willing to help in most cases. The variety of opportunities available in services and events are well supported by the

community as a whole. All the services for youth.



APPENDIX I We are lucky to live in a college community, it brings cultural events and diversity. Services/support of a small community. We do have a health care clinic. easy access to everything youth center clean, safe, cultural opportunities available, plenty of outdoor activities, Speare hospital, doctors

offering reduced fee health care to people in need. strong sense of community we know almost everyone, services are accessible there seems to be a lot of communication between service providers childcare system It's close to Plymouth. It's small, getting to know people - having Pemi Youth Center, the clinic and meals for many. Small town atmosphere, cultural pursuits. Everything close to town. The resource centers. Whole village, circle program and Genesis. There's so much available to

help the community and each person who asks in the community. Support groups. Doctors and mental health. The willingness of support services to want to help and be supportive. Access to Plymouth library, parks and recreation, hospital. The people and the cultural opportunities are very important. The beauty of the state tops the

list at all seasons. The small size and accessibility to most services. good people; community arts, recreation and sports, PSU-related activities and facilities The physical space we can opt to have in a rural community combined with the closeness of a

variety of social activities. Whole Village SAFETY, LOW CRIME (7% of respondents)

Less crime. A nice small town with a low crime rate. I don't worry that bad things are going to happen, as much as I would if I lived in a city. Generally low crime. Safe neighborhood Safety, Bristol is a safe place to live. Crime rate is better than surrounding areas. It's quiet, crime "free" practically, friendly. Country setting. Not a lot of crime or violence. Not as violent and congested as cities. I feel safe there. There is available help if needed. It's quiet. Don't have to worry about violence or crimes like you do in cities. The community is very kid friendly and safe. Less crime than larger areas. Safe



APPENDIX I Low crime rate. Low crime (3 comments) small community- crime isn't as prevalent as in urban areas low crime, healthy environment Crime very low Area beauty Neighborly people Lack of violent crime. that it is a friendly community with little crime safety and friendliness safety clean, low crime good people relatively safe and congestion free it feels safe & friendly; it has a real clean environment Small, not too much crime. Safety Small town, safe. It's small, quiet and relatively violence free. Feel safe in my home. Crime is really low. The crime rate is low, people watch out for each other and the air is healthy The police are fairly on the ball, There are a lot of agencies that do referrals and it seems like a

safe place to raise children. it is small and safe not only is it beautiful but its reasonably safe Safety, good place to raise children It's Overall A Safe Place To Live

GOOD SCHOOLS; Educational Opportunities (2% of respondents)

Good schools. I like my kids school. The tremendous schools. Some nice schools like New Hampton School and New Hampton Montessori for little kids. There is great support in the schools and lots of opportunity to get involved in the community

service projects. Educational opportunities Fresh air, less crime, good school programs. Great schools. Wentworth Elementary school is FANTASTIC! I have four adopted children with special

needs. Three of which have been in the school at one time. The school goes above and beyond what is asked of them and is always looking in my child's best interest.

school beautiful undeveloped spaces, great schools, Thornton Elementary and Plymouth Regional High

School Safety, schools



APPENDIX I OTHER

I don't live forever. Very nice area. Nothing! NH is a great state. It's ok. In most part - health - minded people. The good outweighs the bad. There seems to be a lot of resources, but they are not promoted well outside of local agencies -

there should be a paper listing all community events in the area and community resources that are free.

Very few MA. People It's beautiful and peaceful here. gay marriage is legal!• minimal invasion of privacy by "do good" services that everyone demands and no one can pay

for The people are all in the same "fix" with the "economy" try to live as best we can and be happy live in a beautiful place, but it’s what you can’t see that need to be addressed no one really cares or is informed in legal issues, medical issues No 24 hour police in Lincoln. Great state, nice people Community services when not taken away. The cities. Community needs to pull together and help. If they have information give. Don't know Lived here all my life. Live free or die After living here for 35 years- I'm asking myself the same question. The best about where I live is distance from all the outside influence I don’t agree with



APPENDIX I

Question 7. What do you think is the most difficult thing about living in your community?

LACK OF TRANSPORTATION/PUBLIC TRANSPORTATION (18% of survey respondents)

Being far away with no transportation. Not having any public transportation. Difficult public transportation. Transportation (15 Comments) Geography - need public transportation. Getting around, there is no bus after Wednesday. getting from place to place if you don’t drive Getting to and from services. Hard to get around without a vehicle Inability for individuals to access services due to the lack of transportation. Lack of integrated public transportation. Lack of local transportation (10 Comments) lack of public transportation and lack of employment for some Lack of public transportation and vision for the long term benifits to our community and the

earth. Lack of public transportation is a huge challenge, especially for those who cannot afford an

automobile. This area really needs more public transportation than just the seniors bus and the college shuttle.

lack of transportation Lack of transportation for the public. Lack of transportation for those who need it. lack of transportation, public and affordable!!! Local public transportation Local transportation. No public transportation (9 comments) no public transportation everything is spread out No public transportation to anything No public transportation to get to appointments or resources no public transportation, few sidewalks, safe road side biking walking areas No public transportation must have a vehicle for everything. No public transportation. Cost of living. No public transportation. Services & store too far away. No public transportation. Not a lot of non-judgmental support available. no transportation if you dont have a car no transportation (4 comments) no transportation for seniors on those who do not drive No transportation without good car no transportation, low budget



APPENDIX I No transportation. It's a struggle to rise above "below poverty guidelines". public transportation is not available Public transportation (7 Comments) Public transportation - access to needed services. Public transportation for seniors. Public transportation or volunteer transportation public transportation! Public transportation, access to health care. Public transportation, especially as gas prices escalate. Minimal public transportation. Marginal employment opportunities. Heating costs - long cold

season. Road safety (or lack there of) for walkers and cyclists. Not enough public transportation in the area. Not enough public transportation. With the rise in the price of gas, available public transportation. Transportation challenges. Transportation - availability and cost. Transportation - especially for transitional teens - after high school but before...? Lack of

options for them regarding transportation, training, jobs Transportation and jobs. Transportation by handicapped equipped vehicles. The taxi is expensive and not easy to get

into. Transportation for carless people. transportation for those who do not own a vehicle Transportation for those with disabilities. Transportation for those without their own car is expensive or impossible. ie: Health care for

bariatric surgery is available in Concord limiting it's availability for many local residents who need it.

Transportation needs. Transportation to access serving in community. transportation to different places Transportation to Plymouth from outlying communities. Transportation! transportation, opportunities Transportation. Limited services tough to get around, not a lot of public transportation There is very little opportunity to travel if you don't drive. no public transportation for anyone who is not elderly expensive gas, lack of public transportation TRAVEL DISTANCES TO SERVICES/COST OF TRAVEL (13% of survey respondents)

20 Miles in different directions for major shopping. a lot of specialty services are available far away only Access to many services, long distance to movies, specialty shops. Being close to services



APPENDIX I being far away from medical specialists - typically have to go to Dartmouth Hitchcock Medical

Center in Lebanon or somewhere in Concord or Manchester Being so far away from this, not enough options. Getting around, gas, etc. Children have to be transported distances. The cost of living makes it harder for people on

fixed income - need to travel lots to get to where you need to shop. Commuting and transportation are very difficult and costly. cost of traveling to get anywhere Difficulty for students to participate fully in after school activities because of the need for

transportation everywhere. Also, too many adults driving too many cars due to the rural nature of living.

Distance distance around Newfound lake Distance between town for food, clothing and medical care. Distance from everywhere else! Distance from medical specialists - particularly those treating life threatening illnesses. Distance from services, errands, and appts. Distance from services, stores, etc. Distance from some services. distance from specialty health and family care services distance to a store distance to emergency medical care Distance to more diverse shopping and extended health services. Distance to services distance to services and shopping Distance to services. Distance to shop, work, school, church. Distances between the 7 towns. driving everywhere, distance driving everywhere expenses, long distance for goods and services Far away from everything. Few nearby resources- long trip for fresh groceries or specialty healthcare Gas for traveling Gas prices. Getting around. (3 Comments) getting from one place to another, here to there Having to drive 30 minutes to find activities. Having to drive everywhere! Having to drive long distances to get some services. Having to drive quite aways for better opportunities having to drive. No good access to the airport. Public transportation east to west.



APPENDIX I Having to rely on personal transport with little public transport. Having to travel for health/mental health care, fewer resources available. Having to travel to Tilton where things are less expensive. Having to travel. Housing & transportation If I didn't have my own transportation that would be most difficult to get around. It is really far from drug and alcohol treatment centers. It is remote - no nearby services - travel to services is required Lack of variety for shopping. Distance to health facilities. large geographic spread. Lack of access to transportation and close services for many Limited resources in small town (esp. transportation). Have to have a car to get to work,

appointments, etc. Limited transportation, limited job opportunities. location Location - travel to go anyway. Higher gas prices with tourist area. long travel times Must have a car to get around. Need a vehicle to get anywhere. So far from so many things. So rural/transportation. nothing is close- have to drive to everything. if u dont have a car- it is difficult to get anywhere Shopping in Plymouth area = 10 mile trip each way; gas prices are climbing. travel distances The amount of time it takes to get to stores, doctors, etc. The rural nature of the community. You have to travel to find services or to go shopping etc. Travel (2 Comments) Travel distance to get to services. Taxes Travel to first class health facilities travel, winter Traveling for good extra curricular activities for my kids (dance, karate, etc.) Traveling so far for decent shopping, no competition with Hannaford & Walmart Traveling to city for education programs and medical care. Traveling to most facilities requires an automobile; great distance, no public transportation

options (Rail or bus). Town is 15 minutes away from home. JOBS/EMPLOYMENT OPPORTUNITIES (8% of survey respondents)

"no jobs" and more lay-offs...no money a variety of interesting, stimulating, good paying, good benefits jobs for young people especially Access to jobs especially those with health care benefits. no job opportunities Employment opportunities



APPENDIX I Finding a good job with enough pay to afford the cost of living. finding a job that pays enough to live comfortably Finding a real secure job and housing. Finding jobs and public transportation. Hard to break thru with a new business. High unemployment or underemployment I would like to open a business here, near home but the community doesn't support local

businesses enough. Need jobs & opportunities. Job opportunities Job opportunities, there are none. Job seeking Jobs Jobs and quality, affordable Jobs, there are limited job opportunities in Bristol Jobs. there are none. Lack of job opportunities (2 Comments) Lack of jobs and industry. Lack of jobs Lack of jobs. It needs more jobs. Lack of jobs, public transpo, Lack of employment - no public transportation. No insurance Lack of employment opportunities lack of employment opportunities and lack of transportation, limited financial help at speare

hospital Lack of employment opportunities. Lack of QUALITY paying jobs AND employers! HIGH property taxes --being 'bled out' !

EASE of getting state assistance for a variety of programs which causes ABUSE/FRAUD of this availability

Less job opportunity. Limited jobs. No jobs (2 Comments) Not a lot of job opportunities and transportation issues. Not a lot of job opportunities. not enough job opportunities Not enough jobs Not enough salons hiring. Opportunity Sustainable job opportunities There is not a lot of job opportunity. The unemployment rate. There are not a lot of job opportunities and it is two hours away from a major metropolitan area.



APPENDIX I ACCESS/AVAILABILITY OF LOCAL SERVICES (mental health and dental broken out separately below) (7% of survey respondents)

Access to free health clinics. Access to health care. Access to legal aid lawyers or pro bono is near to impossible for those who really need it. Access to medical services for the uninsured. Access to programs. no access to doctor for myself or dental Getting the services I need. difficulty in getting services for family in rural areas Fewer resources and less access to services. Fewer resources available 2/+ small population. I love that it is a small town but this is a problem as well in terms of variety of available services,

and privacy. Inadequate access to semi-emergency health care. knowledge of and access to services Healthcare Lack of access to services, transportation Lack of parenting support. lack of resources or fragmentation of resource information. access them due to lack of transportation and parental involvement. Lack of resources. Lack of retail options lack of various types of support for people in need and lower class people limited choices of food, shopping, physicians Limited choices regarding employment and health care choices. No, grocery stores in the downtown area. Access to affordable local foods. No medical help, help for inside homes includes neat etc. Not all services available. Not being closer to services Not enough services (2 Comments) Not having services for my daughter with autism. Not much for children with needs. Proximity to more specialized care, dermatologist or orthopedic specifically. there are several

orthopedic doctors but wasn't impressed with their services. ended up over in hanover. small towns don't always have the services available that the citizens need without having to

travel very far to get them So far away, no one want to come to the older people to help. Sometimes it is difficult to get some services. Tri-Cap is now in Ashland and mental health in

Laconia. We don't have many services were I live--we are 20-30 minutes from a grocery store, movie

theater, restaurants, etc.



APPENDIX I Try to get health care from doctors who will not treat new patients who only have medicare

insurance. There are not a lot of resources readily available as there are in the more heavily populated areas. There are not enough resources to help everyone who wants to have help There's not enough help and info about what services are available. There isn't enough services for everybody that needs help so people that really need it go

without and my neighbor is so naughty. No peer support. Lack of stores being open later ACCESS TO MENTAL HEALTH SERVICES (1% of survey respondents)

accessibility to mental health services The mental health field for teenagers is very difficult, especially when it comes to drug and

alcohol situations. The counselors are busy and not taking new patients. It is also difficult finding someone who is in the local that is not part of Genesis.

Lack of resources to support someone that requires mental health services, but that cannot access to mental health services for low income residents and those without health insurance. not a lot of places for people with mental or psychological issues. mental illness people in a small community have blinders on concerning mental/emotional dxs. A lot of biases. lack of psychiatrists ACCESS TO DENTAL CARE (1% of survey respondents)

No dental care Access to dental services for the uninsured. Accessing dental services without money or insurance. Dental care. HORRIBLE for dental care for adults with no insurance and no income (I have yet to find

someone with 5 broken teeth). Lack of dental care no dental insurances for poor poverty class. LACK OF PHYSICAL, CULTURAL, SOCIAL ACTIVITIES; and related environmental supports (7% of survey respondents)

Lack of activities for our children or more that are affordable. lack of arts & cultural events Lack of cultural opportunities & public transportation. Oh yeah, JOBS! Lack of exercise/relaxation facilities for non-PSU people Lack of family orientated affordable fun things to do and lack of public transportation It is not pedestrian/bicycle friendly. lack of paths for walking, running, biking, etc no community center Lack of services LOCAL! No after school activities/clubs. Lack of services.



APPENDIX I lack of side walk or bike lanes, along route 3 north of town center Limited quality family activities. Limited social and cultural opportunities not a lot of activities (adult sports and child playgrounds) Not a lot of activities to do. Not a lot of cultural opportunities no access to afterschool and summer programs for children. Not as many resources, cultural events, sometimes feels like too small of a population-no

anonymity Not as many things available to me as what I was used to prior. Like a workout or gym facility. Not enough activities nor places to go to do things and not enough places for support, for those

who have disabilitities. Not enough activities, like movies, entertainment during late afternoon and nights. Area is

almost dead, with no place to go. Not enough activity. Not enough age appropriate play groups for children and parents. Need to let parents know

when/where to go for them in many towns surrounding Plymouth. Not enough community group activities. Play group needs to be run by one

person/organization, not a group member. Better community center. Not enough free programs for children 10-teenagers. No specialty MD's in area. Food pantry

foes not give enough and fresh & frozen food (a lot) are no good Not enough social activities for young adults besides bars - drinking activities. Not enough

employment opportunities for semi-professionals. Not enough to support a Y or such. Not enough walking/biking access/paths. Dependent on auto, no public transportation from

town to town for anyone but seniors. Not much available for entertainment. Not much for children. Nothing to do Sidewalks and roads in poor repair, makes walking, biking difficult. could be more community events Younger, peoples "hang out" not enough for young people to do; they tend to move away The lack of access to more social activities and late night hours of restaurants and store open. The lack of things to do because of the small town atmosphere The rural qualities and lack of opportunities for kids to keep busy, especially on the weekends,

evenings. Lack of social activities for older youth and young adults. There's nothing for children there's no place to go to enjoy for free for seniors--like--exercise room and pool--basketball

court--tennis court There is no gyms that are affordable for single mothers with nutritional ideas, lack of availability of exercise pools etc open to public, gyms



APPENDIX I lack of children's recreation FINANCIAL BURDENS; taxes (6% of survey respondents)

Financial Burden Of Taxes financially there is no help, no good programs from school for kids after school I'm struggling financially, wish there was more people that could help. Lack of money. Amount of under privileged people Due to the seasonal nature of much of our employment base, way too many people live too

close to the edge. It's a poor community and many people take for granted they will get help. We forget how to

help ourselves. no break on property taxes for seniors. not enough local help for those who are just over the guidelines of welfare and food stamps Not enough MD's or programs for poor. thrift stores, getting real $. not making enough money to live People are house "poor". Property taxes are high and people tend to not vote for any services

that will increase their property taxes. Towns need other sources of revenues, other taxes. Prices for food and gasoline, trying to get help for something and they think you make too much

money!! Seeing so many kids living in poverty. Taxes (4 Comments) Taxes (property) Taxes going up for middle class people. The economy. Town administration/administrators out of step w/economic hardships in this town. (Spending

$ we do not have, making it too expensive to live here and it is NOT a hub). The extreme poverty. In Rumney, half the children qualify for free/reduced meals. Alcoholism

soars because people are stressed. Abuse increases. People can only afford to eat junk and God forbid if you get sick!!!!

When things are being taken away and making life harder for the lower income people. The prices of everything. very poor people that do not make good choices for themselves and families watching people struggle to make ends meet, homeless people Trying to get help to pay for utilities like the light bill. Not enough financial (town) help they're very strict on what info they need and want to matter

what. low incomes, cost of living is high There seems to be fewer jobs available for full time work, and incomes have not increased at a

rate even close to the costs of groceries, heating oil, gas for transportation, taxes, and more. It seems like a high cost of living

gas prices high economic support for families



APPENDIX I Cost of energy Heat ISOLATION OF RURAL SETTING; COMMUNITY CONNECTIONS; DIVERSITY (5% of survey respondents)

Is rural and getting what you need or finding out what is available can be difficult. isolation Isolation and access to adequate services Isolation and the lack of community for young families w/professional parents. Isolation due to lack of public transportation. isolation for single people Isolation for those living in some of the more rural areas and poverty for many. isolation, lack of services it is isolating living in a rural setting with intermittent transportation it is not close to more family supportive resources (i.e. lack of jobs, opportunity, for young

families) It's rural. It's rural. It is already hard to be accepted into programs, or into doctors’ offices, and then on

top of that most places aren't within walking distance, you need a car, or a ride, gas money, the ability to take a day off of work to travel.

High priced utilities, gasoline. Personal isolation in rural areas Being gay lack of diversity, specialty retail options for ethnically diverse individuals No one cares about each other. Not knowing other people physically spread around too much Remote location, inadequate access to services in distant towns, lack of racial/cultural diversity rural isolation Rural isolation is a problem for those who don't drive or work. rural... Sometimes because our small communities have such polar opposite views, it is difficult for

town governments to get things accomplished. Also, our communities can feel isolated sometimes.

sometimes people are close minded, community is not as diverse as I might like Would like people closer to the town. The distance between all the surrounding communities. Rural area when help is needed we live just far enough out it takes a while for help to get here We are kind of remote or in a remote areas so a lot. The lack of diversity. It begins with the lack of cultural diversity and trickles down to everything

else including food choices, art, music, recreation etc. People can't learn tolerance if they don't experience differences in every aspect of their life. Bringing a 'Multicultural Market Day' to the Plymouth area would be amazing.

The size of the community - sometimes people just aren't accepting enough of differences.



APPENDIX I establishing relationships with members of the community WINTER (3% of survey respondents)

Cold winters! Cold winters. Getting through winter. Winter (3 Comments) Long Winters and isolation Long winters. (2 Comments) The weather in winter. the weather is oppressive Snow removal the long winters, as a person with a disability it is hard to get out much, no public transportation Isolation, long winters, heating costs The cold weather and long winters. Weather The snow sometimes. Too much snow. Transportation HOUSING (3% of survey respondents)

cost of housing Finding housing with a garage. High rent Housing & transportation Housing decent affordable housing (too many slumlords) Lack of affordable housing. limited reasonable rents price of housing The lack of housing, transportation Unaffordable houses, trailers or apartments. What's affordable gets taken. If you can't work or

find work or keep work, low income housing is very difficult to get approved. There are not many low income housing programs or programs to help low income people get

dental care or eye exams or really any services. poor housing We need more Sec. 8 housing for singles/elderly low income housing (2 Comments) ALCOHOL, TOBACCO & DRUG USE (2% of survey respondents)

All the drug use. Board (?), drug use, alcohol use Kids doing drugs and alcohol. Drug use and alcoholics.



APPENDIX I Alcohol & drugs. Lots of drug and alcohol problems -adults and kids Drugs (2 Comments) Nothing except seeing young teens smoking. Prevalent substance abuse Streets are full of drugs, getting help for disability. Too many drugs & people walking streets that police know about. PROXIMITY TO THE COLLEGE/COLLEGE STUDENTS (2% of survey respondents)

College College students not living/partying on campus College town. Dealing with drunk college students. Disturbance issues with off-campus college students, excessive drinking and availability of

alcohol. inconsiderate college pukes The road down town is not wide enough, college kids are always around. Negative influence of college living in residential areas The college kids being drunk at 3:00am cause mischief. the college students, lack of local jobs Traffic, too many college kids driving. Hard to get across streets, have to wait a long time. The stratification of full-time residents in the off-campus neighborhoods poses continuing

problems. Traditional residents are becoming more and more isolated in these areas, and increasingly frustrated by the unresolved quality of life issues.

NOTHING (2% of survey respondents)

Can’t think of any Nothing (7 Comments) None N/A CRIME (1% of survey respondents)

Crime (2 Comments) Crime is one of the biggest problems that I see is underage drinking and prescription drug abuse. Crime, theft Some crime. Youths in 20/30's causing disturbances/crimes. So many young children without any parents at

home. Police harrassment of mothers with young children. crime, bullying/cyber bullying in school LACK OF CHILD CARE (1% of survey respondents)

Finding child care for single working parent hours. Daycare for children



APPENDIX I quality, affordable, and adequate child care adequate child care OTHER

Bad roads, crooked cops. class distinctions Discrimination - kids not getting enough help in school. expert doctors Factionalism between retirees on limited incomes and families with school aged children breeds

antagonism. We must find a better way to knit these constituencies together. How the elderly are not used for experience and or first asked to contribute. How they are just

not included. Finding help when needed. For the reason above often confidentiality is an issue. Garbage on the road and cigarettes thrown everywhere. Lack of a good cable TV package. Too far away from shopping malls. Getting help. Getting things done that would make a difference. Having/Finding people who will listen. Reversing the "rumors". Lack of connection..2nd homeowners Lack of the poor condition of streets and sidewalks. Repairs, especially to sidewalks needed. Lack of understanding of what's available. Law Nepotism. No 24 hour police in Lincoln - oops - I live outside your bubble. No parking or little downtown. not a lot of volunteer programs accessible, Not everyone can get help!! People (neighbors) know every time you need to ask for assistance. small town community, knowing your neighbors some breeches of confidentiality issues People abusing the system - using ED as primary care. People can be judgmental and uneducated. people starting rumors seeing traffic lights, big stores come in. it will attract city people and more garbage on lands,

crimes will come. gas prices, elect, high, people coming in changing things and there are not from here. and its not to help our community or state. (seeing homeless people and animal abuse)

Segregated haves and not haves. small town cliques and people who want to make our state like the state they moved from support groups the bears When I have to go back to the city.



APPENDIX I The expansion and growth, like for example another pharmacy even though Plymouth already

has 3 I believe or 4. The MA. people that are there. The young teens who hang around town at the local store, it's uncomfy to wait to go in when

you have an anxiety disorder. Trying not to volunteer for everything that you see a need in doing to help out non-profits and

community partners.



APPENDIX I

Question 8. If you could change any one thing that you believe would contribute to better health in your community, what would you change?

HEALTHIER EATING/ACTIVE LIVING (11% of survey respondents)

our health would be much better if we could have the right foods Better food choices Educate about better food choices, re: processed foods are bad, eat natural. Education on eating right and exercising. education on health living - exercise and food Everyone needs to plant food and recycle. healthier food choices and more exercise opportunities in the schools, especially middle and high

school. healthier foods at school and increased exercise (mandatory gym) Healthier foods more affordable healthy eating habits. More exercise programs, bettr eating habits. Healthy food options school lunches, more exercise for the kids Help people realize how important healthy/quality food choices are. Learning about good food choices and exercise. better food banks (no MSG, etc.) make it so that only high quality, local & organic produce and food was available Teaching children about good food choices quality food - glad to see our famer's markets Restaurant participation in healthy foods More affordable fresh food. Ability and Knowlege of providing healthy meals is MORE economical than the crap that is

purchased for less money~ Offer Resource for budgeting and skills to shop and prepare meals! A facility especially for seniors to go to exercise on machines and go to a pool for no or little

cost. Access to physical activity opportunities: bike paths, sidewalks, community exercise classes etc. An accessible gym that does not have a waiting list, is affordable, and doesn't compete with

existing student programs. An activities center family with AFFORDABLE activities and exercise classes Celebrate health and exercise. Community exercise program Community focus on healthy eating, exercise, and weight loss. exercise programs - more walking and trails Facilities for indoor exercise in the winter. free or low cost exercise classes open to the community low/no cost exercise opportunities Have free weight loss/exercise classes available for all.



APPENDIX I try to get more people to understand what a huge effect exercise has on their health followed by

nutrition. Town swimming pool great exercise and would also make summer recreation programs more

exercise orientated as opposed to so many trips Require every resident to exercise. respect and courtesy of bikers (bicyclists), runners and walkers Opportunity for adults to participate in local activities like softball or other sports. Outdoor activities, exercise. Nutrition education and support groups. Obesity and healthier life style with exercise. more reasons to get out and exercise More free nutrition and exercise programs. Lower cost exercise locations for all ages. More exercise programs. Weight reduction. Safe, liveable, walkable community. a community fitness center, maybe a gym. add bike trails system; bring in a YMCA community center with many activities for all ages both

indoors & outdoors Being able to use facilities (pool) at University Big gym (low cost) ie: Planet Fitness bike and walking routes everywhere people shop, Bike paths Bike trails (trying to avoid hills when possible). Use of old railroad tracks for biking, walking, etc. community programs for fitness and health eating habits Farmers markets would be good. sidewalks and walking areas to encourage fitness Sidewalks/shoulders so people can walk or bike more safely. Improve the school lunch program by providing healthier choices. Plymouth should have a public park, with a large year round maintained walking path, dog park

section and children’s playground. people in general should walk more People should walk rather than drive. Walking has a direct effect on health. Bike lanes & walking. make community "fitness" a priority. Doctors encouraging exercise and healthy eating. Maybe speed limit for safer walking with children. ACCESS TO HEALTH CARE/AFFORDABLE CARE/AFFORDABLE HEALTH INSURANCE (7% of survey respondents)

Access to health care Access to health care and affordable health insurance.



APPENDIX I Affordable health & hospital care. Affordable health and dental care. Affordable health and dental for all. Affordable health care Affordable health care, especially for the elderly who are on a fixed income Affordable Health Insurance better access to affordable health insurance and education aid country wide single payor health insurance Health Insurance for EVERYONE! Health insurance having a sliding scale. Health insurance to independent students. Make health insurance more affordable. A change I would really like to see would be for everyone to receive excellent dental and medical

care, with little to no out-of-pocket expense because of insurance coverage. Available care for everyone. Lower rates on insurance better health (more affordable) insurance Better insurance access Everyone should be allowed to get affordable health and dental insurance. More affordable public health care. More availability for health/dental care. Access to low cost health care that won't put you into debt. Access access to programs that allows for low income residents to be able to afford health and dental

care. Accessibility to services & incentives to use them. Affordable access to medical care for middle income people. better access continued opportunity to receive reduced cost health care at doctors offices and at Speare

hospital Universal Health Care (single payer national program) Single-payer health care. a national health system easier access to sliding scale payment care. Have reduced health care structured to your income so everyone could afford not to be sick. Health care initiate a single pay inclusive health care system More access for those in need of services More payment plans to people who cannot afford health care and have bad credit. Especially

for dentures for adults. Health care for everyone, I support president's health care reform. I would like to universal health care



APPENDIX I LOWER THE COST OF HEALTH CARE (1% of survey respondents)

The price of health care. The cost of being healthy. Cost Cost of quality care. Price of medical care; more clinics. Lower health care costs. FREE HEALTH CARE (1% of survey respondents)

Free clinics. Free dental care for adults with low incomes Free health care for everyone! The need to improve free health care and free transportation for seniors. Free health clinic for the uninsured. EXPANDED CAPACITY, QUALITY OF HEALTH SERVICES (8% of survey respondents)

A clinic every day. A community health center Access to a range of specialty providers. I am a part of the evaluation process and then I send

families out with recommendations based on very limited resources especially in lower Grafton Co, where I also reside. Mental Health choices are limited and there can be wait lists, services for children outside of what the school provides means families traveling long distances (OT, speech, PT etc), Early Intervention services are sparse due to travel and availability of specialists traveling to a 'remote' location.

Access to health/relaxation facilites for non-PSU people walk in clinic. smaller cost than er visit, but still available on the weekends, late evenings when

something comes up. example, kid with strep throat. don't want to pay for ER visit, but can't wait until monday.

A place where people can go once or twice a month for their advice on their medical/mental questions or some type of group to help.

More doctors’ offices, or an easier way to get to already existing offices if you don't have transportation.

Add more walk-in clinics. Added health care Better access to medical specialists/treatments there should be more dental and primary health providers for people who can't afford it. Clinics who still treat ill patients. Closer access to medical specialties. Closer medical help! community based clinic the hospital Speare Memorial hospital



APPENDIX I Dr's. - can't find a good one. expert doctors The health professional listen with great understanding and compassion to their clients. Go back to having a local doctor, when Speare Medical Assoc. offered a satellite office in

Campton, the physicians seemed able to take more time to hear and understand my health issues.

Health care availability Health care close by - more walk-in clinics. Revamp the funding and support system for the non-profit community so that there is more

long-term sustainability of services and supports More opportunity for health care. Help NANA with donations and volunteer. Increase state revenue to fully support health services for the most needy. Increase support for at risk families. increased funding for needed services More & closer health providers. More care from service providers. more clinics More clinics or easier insurance qualification. more smaller clinics to treat common minor problems, for minor health issues that would help

reduce travel time. i have to drive 1 hour each way for appt more walk in clinics that do not charge rates if you have gone to an ER More walk in health clinics and health education. More doctors More female doctors available. More female doctors. more free clinics More funding More health care clinics More inexpensive health care. More inexpensive/free early intervention health opportunities such as: vaccination clinics. more private owned offices, when they become too big, the doctor-patient relationship is

diminished. more programs services available for young people and people with a disability, elderly

TRANSPORTATION (6% of survey respondents)

Access to public transportation (2 comments) Access to transportation Better transportation. Transportation (2 comments) transportation availability transportation infrastructure so elderly could access services Transportation needs and cost of activities for children.



APPENDIX I Transportation to access medical, mental health, and other services. Transportation to access medical,l mental health, dental care. Transportation to appointments and for home care. transportation to medical facillities Transportation!! Public transportation for everyone. Public transportation so the poor and working class citizens of our area can get to their

appointments. Public transportation. (10 Comments) Put in public transportation. public transportation - we have none public transportation for elder adults to access medical professionals More public transportation. low cost transportation Create a place to call for transportation Increase public transportation opportunities I believe that transportation would be helpful for everyone even transportation to people to

assist others in understanding their benefits. Have transportation - public or assign Volunteers to people in need. public transportation local taxis who accept EBT pay system $80 mo. in transport costs Easy, non-stigmatizing access to public transport for elders and families to help manage fuel

costs and keep poor driving elders of the road. RESOURCES FOR YOUTH, FAMILY, COMMUNITY SOCIAL & RECREATIONAL ACTIVITIES (6% of survey respondents)

A bowling alley, a dance club, something to offer inexpensive social activities for young adults away from house parties.

Availability for youth to participate in a pro-social, healthy lifestyle activities More work places. More places to socialize. More expansive youth center that is geared to things teens want youth activities at low/no cost We don't have a youth center for teens to go to stay active. Youth Centers (activities) Parental involvement with children and more opportunities for youth activities. Kelley Park

needs shade and seating, otherwise no one uses it during hot weather. more community events and access to them (transportation) more community centers and recreation opportunities Affordable community activities. Better affordable access to wellness centers like a YMCA Better parks & rec. build a community center build a public recreational park with athletic fields including a track in Plymouth



APPENDIX I Build sidewalks!! So you don't have to walk on roads or mud children need more activities to keep them out of trouble and healthy. baseball = expense

sports = expense low income needs help for children, library need to offer local things, need to ask children their interests

community center Community center for child and adult activities. community center with activities for all ages; a community pool and fitness center Community events for family and young children. Create YMCA - like facility Daycare & fitness class. Gardening More handicapped (wheelchair) accessibility to stores & shops in Plymouth, Lincoln,

Woodstock, Meredith. Something like a YMCA. A lace to get fit and stay fit. I would appreciate opportunities to meet people in the community that are my age (40+). I would have fun activities at least 2 times a week at town hall. Something so people can get out

of the house and interact with others. I would like to see more adult based activities available, such as dance classes, community sports,

etc. that are not too expensive so that any social class can participate I'd make more community events that are geared towards people in their 30-40 range the music

on the common is older music, and there aren't a lot of options, more activities that are more affordable More bike paths, skateboard parks, sidewalks. Increase community activities like the Plymouth downtown halloween parade. Opportunities to safely walk/ride bicycle/share rides to get places. More access to arts & cultural programs. More outdoor spaces. More local/available places to take pets. ALCOHOL, TOBACCO AND OTHER DRUG PREVENTION & TREATMENT (4% of survey respondents)

Accessibility to illegal drugs. Encouragement of more people, especially younger people not to smoke or to stop smoking.

Access to low cost or free smoking classes. stop selling cigarettes!!! stop smoking programs Smoke-free environment Smoking banned in public. Quit smoking program No drugs, more exercise. No smoking in public anywhere, anytime. I'm tired of walking through 2nd hand smoke. outlaw smoking Better public education regarding alcohol & drug addiction. Especially prescription drug abuse. Drug/alcohol treatment program.



APPENDIX I Drugs delivery of drug education to be more effective, parenting education for 0-5 years old, the critical

formative years improve drug and alcohol programs More strict regulations on underage and binge drinking at Plymouth State University. More things to do, there are too many teens and adult addicted to drugs and alcohol. We need

to get them off the streets. drug and alcohol problems. More opportunities for work and lessening of chances for alcohol, drug from boredom. People

need goals and a purpose. Drug treatment for youth. Cigarettes thrown. Close bars, make music in other places. Get rid of the pain care clinic that is used by so many people to get scripts for pills that they

don't take but sell instead. Everywhere you turn in the newfound area you can find someone selling percocet, oxicotin, methadone etc. I personally have seen a huge increase in the availability and amount of people buying those meds illegally

have a day treatment center put in. Shut down Hippey Hill I would have an affordable treatment Ctr. Obnoxious college students, Strict rule of noise complaints. Seriously pick up the beer bottles

everywhere!! EXPANDED ACCESS TO MENTAL HEALTH SERVICES (4% of survey respondents)

Accessibility to services for those who wish to be mentally well and to move forward into financial stability.

Better access to mental health programs. Better mental health programs and for parents with behavioral health issued children. services for people with disabilities/ mental health care More, and more affordable, mental health care Need more mental health resources locally. More mental health support. more open mindedness to mental health and well being More Mental Health Centers, and Resources Centers More mental health support for all ages and mentoring for young males. More parental involvement and support for parents that are low-income and have children with

special needs and or mental illness Access to better/available mental health/drug & alcohol, abuse facilities. I would increase availability of mental health services I would want to see more help for old & young people who have mental illnesses & diseases. Mental and general health coverage for all.



APPENDIX I mental health -- helping young and old full term living, safe environment, getting them the help

and education that they need. safe from the streets. And homeless people in plymouth, seeing the guy we see all the time breaks your heart

Mental health care Mental health services for you is very poor in this area. Mental health services provided in town. Mental health visitations at homeless shelter with people that can be trusted Having services

come to you in situations such as the senior center and homeless shelter. Increase mental health services. More access to social services, e.g. counseling/mental health services, adult day care. More community mental health services for the population without health insurance. more extensive mental health care services for both teens and adults locally more for mental health more help for those with mental health issue EXPANDED HEALTH EDUCATION, OUTREACH AND WELLNESS PROGRAMS (4%

of survey respondents) Add more wellness programs. advertising where services are available and what they are better education of services to locals A community outreach!! To better get health information out to people who may not have the means to find this out for

themselves. To make sure the people that need help, the info needs to be put out there and on local TV. sex ed for teens. Education program for kids that have nothing to do . emphasis on promoting health vs treating illnesses simpler and user application for success, many do not know how to find service health education Health programs for community members. I'd educate the community more on all social issues. if there were more places to get help and more widely known to people promote healthy lifestyle choices, make them easy to learn about, access and use Increased educational resources. Parents who do not respect their children program to increase children's self esteem more education about health and wellness More free workshops and groups, nutrition, mental health, etc. Transportation to and from

appointments. More info and referrals to meet needs of people. More opportunity for health care - prevention! JOBS/JOB TRAINING (3% of survey respondents)

"jobs" for people to work in the u.s.a...don't send our life to other country.



APPENDIX I Beef up the vocational wing in H.S. so that kids graduate with a skill to support themselves. It is

getting harder and too expensive for a lot of kids to get into college. Without votech they can't get good jobs.

Easier access to jobs with benefits Education in our community for adults so that they can get better jobs and know more ways to

find services that they may need! Education/job training. Good jobs I guess if I had to pick just one. Job opportunities Job training Job training availability. More job opportunities More job opportunities More jobs. School training for youths to get and keep jobs. The importance of job skills and the training The amount of people that are not working in this area and live on almost no money, jobs,

clothing and health care. Increase in businesses to employ residents who could have health insurance More economic opportunity for more people Access to more employment opportunities within 1/2 hour commute. Wages If I win the lottery, I'll build a great business. So there's lots of employment. COLLABORATION, COMMUNICATION, COMMUNITY INVOLVEMENT (2% of survey respondents)

More participation from local hospital with physician practices in community events or patient care.

Ability for providers to link & communicate for clients/patients best interest - (talk to each other)

A more collaborative community approach to networking/support for parents across the socio/economical divides.

Strong leadership... optimistic and motivational leadership. Team work. Communication. Get to know our neighbors. I would have more time to volunteer. More people worked together to help others when needed. Increase connections for people with similar issues/ concerns for resource-sharing and problem-

solving. Decrease gaps between "haves' and "have-nots" More communication pro and con on health facilities People being more open



APPENDIX I neighbors helping neighbors. Pointing people in the right direction to access resources to meet

needs More meetings involving how we live and to improve life for us all. ACCESS TO DENTAL CARE (2% of survey respondents)

dental care for adults on medicaid Dental care for adults with no insurance and no income Dental care for everyone. dental plans more dental for low income. especially for children More dentist to accept Medicaid I would increase availability of dental services Dental clinic for sure. free or low cost dental care more affordable dental health care Better dental health & dental health insurance for low-0-income families. SENIOR SERVICES (2% of survey respondents)

Affordable housing for seniors to transition to. Better senior housing. Free exercise classes, more transportation for seniors. Free health care for elders. Food for the elderly and home care, sometimes they just need someone to talk to. Pay more attention to the elderly, they are a wealth of information. more elder help Older people help More home health aides for elderly/handicapped. ECONOMIC ISSUES/POVERTY (2% of respondents)

The need more of any subsidized housing available. Based on someones income - rent. there are MANY families/people that fall through the cracks. They make too much to qualify

and not enough to make ends meet Community getting together and helping financially, emotionally, physically. Everyone has tags on cars for disability, we need help getting $money to support family. Have every business give an extreme amount of $, they write off other fortunes. Help people

own houses. No one except the well-off has a house. We all live in subsidy and have no chance of ever living in our own home. It addresses a want, a need of a lot of people. My children deserve their own room that they can decorate and fell secure.

Reduce Poverty Reducing the taxes would reduce a lot of stress among actual taxpayers. PSU paying its fair

share for municipal services received would reduce the tax burden on the traditional residents. Reduction in Poverty Reduction of "disability" fraud claims/payments-would save Money for state, taxpayer etc!



APPENDIX I Remove assistance or make it a must for people to work to get any assistance. lower cost of electricity and fuel oil and gas more services to help people improve their circumstances not just service them

PUBLIC EDUCATION SYSTEM (1% of respondents)

Public education needs to have a major uplift. i believe the entire school day schedule should change and include all students to have therapy balls to sit on rather than chairs, regular and more frequent breads are taken, more education be taught outside the classroom, and that the teacher/student ratio could be approximately one teacher per four or five students.

Better education at school levels, all grades ever year. We should be teaching our kids about the value of money and how to pay cash/invest starting at a young age. Every grade especially 7-12 grade, bank advisors would be happy to teach this. Use community resources.

Financial support for our school districts More emphasis on the importance of education! Stopping the 'politics.'

DOMESTIC VIOLENCE PREVENTION (1% of respondents)

Crack down on domestic violence. Start teaching respect classes in grade school and make it a requirement for graduating. People

need to learn the importance of respecting themselves and others. Voices Against Violence needs to reach more people.

Provide more funding for DV/SA crisis services to provide services in outlying towns. Increase funding for DV/SA crisis centers to do education & outreach Increased support for DV/SA crisis services NOTHING/NOT SURE (3% of survey respondents)

All set Honestly, I'm not sure right now. I don't know (2 comments) I don't really have a good honest answer. I really don't know. None (2 comments) Not sure (4 comments) Nothing (2 comments) can't think of anything at present hard to say. I don’t know what I don’t know health has been fine for me

OTHER

Weed out the folks that abuse the system, reach out and assist folk that are in true need! If folks can afford to smoke, drive a car, cell phone and are obese and drink they should not receive subsidy.

What new businesses we allow to move in. Family run businesses get plowed out when big business comes in. If bigger business is necessary or beneficial then awesome, but not another Chinese place or pizza shop or pharmacy or supermarket.



APPENDIX I winter - can't get outside to walk or play 1 on 1 with doctors, health care, etc. Put a Walmart in town. Thrift store prices at least 1/2 price for under income and food pantries serve food that a

Senator would eat. a doctor that knew all about medicine, low income, mental health, disability problems Develop long term solutions to our needs with the environmental impact as the basis for the

solutions to fulfilling those needs. We won’t be around to worry about the other issues if we don’t start to tackle this one and quickly.

Better town water (tastes like bleach). Bristol Elementary School needs to be a one level school (physically), stairs are steep. understanding View easement tax cheap, affordable programs try to control careless driving of some young adults. Climate The water, so you can drink it. the weather Stop paying the medical/dental bills if you still have a new car, cell phone, fancy nails and

smoke. Help yourself The natural spring where most people get their drinking water should be tested. Fire everyone, start over. Free health classes. Free McDonald's food. Me love double cheeseburgers and fish fillets. funding get rid of the sex offenders Health care money programs Less traffic Laws for health care. Nothing!! Except, have traffic lights in the middle of the square. More recycling sewage treatment plant smell downtown More help.

Appendix II Parent Focus Group Notes

Page 1 of 14 CNHHP Parent Education Class Focus Group

April 18, 2011

APPENDIX II CENTRAL NH HEALTH PARTNERSHIP – COMMUNITY HEALTH ASSESSMENT

WHOLE VILLAGE PARENT EDUCATION GROUP - FOCUS GROUP NOTES

APRIL 18, 2011

The Central NH community health needs assessment included the facilitation of focus groups with targeted groups of community members. A focus group was conducted on April 18, 2011 with adult participants in a Parent Education group sponsored by Whole Village Family Resource Center. The focus group was facilitated by the Community Health Institute as part of a regularly scheduled meeting of the parent group and the evening included a family meal. A core set of questions asked about perceptions regarding community health strengths and gaps, awareness and impressions of existing services and programs, and thoughts on opportunities for improvement. The focus group lasted 80 minutes. All participants were informed that their participation was voluntary, confidential and that their names would not be recorded in any reports or associated with their responses in any way.

Participants: The focus group participants consisted of 18 parents (12 females, 6 males). Participants had between 0 and 6 children in their families. Towns of current residence included Plymouth (9), Ashland (2), Campton (1), Thornton (1), Lincoln (1), Meredith (1) and Northfield (1); (2 unknown residence).

QUESTIONS & COMMENTS

1. In general, do you think the people in our community are in excellent, very good, good, fair or poor health?

Question Summary: The general consensus of the group was that people in the area tend to be in fair to poor health. The reason for this perception, and the focus of most of the comments, is that health insurance is difficult to obtain and the cost of care is unaffordable. In addition to insurance for medical care, insurance for dental and vision care were also specifically mentioned. Participants agreed that the situation is better for children through Healthy Kids, but difficult for adults.

Selected Comments (not a complete transcript): “I would say fair to poor health because it is so hard to get health insurance that I think a lot of people just skip it because they figure I’m not going to the doctor because I can’t afford it.” (Female; Ashland)

“I have to agree with her I mean, because let’s face it you go to the doctor and you get this bill of like $2,000 and all they did was just go in there and say oh you’re sick.” (female, Plymouth)

“And it is really hard to get insurance and medications are exceedingly expensive.” (female, Thornton)


April 18, 2011

APPENDIX II “And up in Lincoln I don’t know of very many people or jobs that even offer insurance, especially dental you notice no one has dental insurance – no one that I’ve talked to.” (male, Lincoln)

“Or vision” (Male, Lincoln)

“Dental or vision are really getting hard to come by now.” (female, Plymouth)

“Kids do get insurance through Healthy Kids, but most adults don’t have insurance.” (female, Thornton)

“Or if they do have it, they have to pay a co-pay of like $150 or $200 bucks and it’s like you don’t have that money – it’s like when you get a spend down or something like that and it’s like you might as well not have it in the first place because you are going to spend the same amount.” (female, Plymouth)

REDIRECTION TO PERSON WHO HAS NOT YET SPOKEN “I would go with fair to poor health. I don’t have insurance and I don’t even remember the last time I went to the doctor because of the cost.” (female, Plymouth)

“You know we just had an incident because dental is not covered. He is on the Medicare program and that’s not covered. He had is teeth problem; teeth had to be removed; not covered and it slammed the family so hard and it was like oh my God what do we do. It was like $300 or something but luckily the dentist was able to help us and got it down to like $150, but it was still crazy high.”

“It was $190 to have each tooth extracted, but he only charged me for 1 tooth instead of 2 because he was just a nice guy and I told him I didn’t have any money.”

2. What do you think are the most pressing health or healthcare issues facing our community?

FACILITATOR: It seems like we have identified the ability to get health insurance, dental insurance and vision insurance as a major health care issue. Are there other issues that are pressing?

Question Summary: Participants identified mental health care as a pressing health issue (6 participants) as well as substance abuse treatment (2 participants). Participants also continued to identify general dental care as a pressing issue as well as specific discussion of limited availability of oral surgery and orthodontic care (6 participants). Participants also discussed the limitations of specialty care associated with area hospitals – to include Speare Memorial, Franklin Regional and Lakes Region General Hospital. Participants discussed as a strength the level of communication and coordination between health care organizations. “The network that Plymouth has for social services is a lot tighter and a lot more in-depth than what the Laconia-Meredith area has . . . . So I definitely got to give this community ‘props’ for that . . . .” Communication and coordination between Genesis and Whole Village was also specifically mentioned as a strength.


April 18, 2011

APPENDIX II

Selected Comments (not a complete transcript):

Mental health <is a pressing issue> (unidentified person)

“I was the owner of a company for about 16 years, but because of the economy it went belly up a about 2 years ago; since then I have been unemployed. I think the economy has a lot to do with what’s going on. The state of the economy right now is in really bad shape, especially around here. I think that is the prime factor – people have to survive. That is what I have been doing the last 2 years. I will do whatever I can do, because that is the only way to make money. That is my prime thing – trying to figure out how to make money. All the other considerations, health insurance, everything, it just doesn’t even matter.”

“Another thing is cardiac care. There is not a good place close by. You have to go all the way down to Laconia for cardiac care. <Specific story of accident; trauma from “a couple years ago”> All they could do in Plymouth was stabilize him, that was it. They couldn’t operate or anything, because they didn’t have a cardiologist on duty to stabilize his heart. So they had to take a second ambulance ride – more money – to get him to Laconia which meant longer distance away from the family, away from where he should be when he is healing. They need cardiologists up there; that’s a desperate need.”

“I don’t think it was a cardiologist – it was something else.”

“I think mental health. I hope they don’t cut the budget on them, because a lot of people need Genesis as it is already and they can’t afford it and now they are getting another cut. I see Genesis and so do my children.” (Plymouth, female)

“Ditto” (unidentified)

“I go weekly, I mean it just really helps. Especially people who go through tons of grief and transition. To hear that they are getting a 50% budget cut. People already can’t afford the co-pay.” (Plymouth, female)

We go to Genesis too. They are very good there, a very good facility. They seem to cooperate with these people here (Whole Village) to some degree, I don’t know how much. People from here know them and they know people from here. That’s the good thing – there is some community stuff going on there. To what extent I’m not really sure, but it seems like there is a good rapport there.

“The network that Plymouth has for social services is a lot tighter and a lot more in-depth than what the Laconia-Meredith area has. There’s no communication between services (in Meredith) and there is here. So I definitely got to give this community props for that, where Meredith needs to step up.” (Plymouth, female – relatively new to area from Meredith)


April 18, 2011

APPENDIX II “I live there now. It’s a quiet neighborhood, it really is. But communication is key – like between doctor’s offices and pharmacies.” (Meredith, Male)

“While Whole Village communicates with Genesis really well here, Genesis is an entity onto itself in Laconia. They’re like an island. They don’t talk to anybody. There is no communication between services.” (Plymouth, female)

“There is Genesis’ down in Laconia too. They don’t even talk to each other. It’s ridiculous.” (Plymouth, female)

“Up in Lincoln-Woodstock area, it’s a small community, but there are no real mental health providers. It’s not really an impoverished area, but a lot of people are probably living close to the poverty level. It’s seasonal employment, so no one is getting any benefits. And there is no mental health. And I know with the economy the way it is people are just living season to season and there is a lot of stress there, but there is no way to really to cope with it.” (Lincoln, male)

“I have to agree that we are better than most areas. I have family from down in New Jersey and they have absolutely nothing down there. We look like we are amazing compared to them, but there are still holes in it regardless.” (Ashland, female)

“Some of them <holes> are really huge. Like the state’s version of dental care is severely lacking, because according to the state of NH teeth are not important. They do not pay for maintenance and upkeep on adults; they do not pay for dental appliances; they pay for extractions only and that’s it. (Other states) believe your teeth are a vital part of your health system and without your teeth being healthy, you’re not going to be healthy.” (Plymouth, female)

FACILITATOR ASKS ABOUT EXPERIENCES WITH CHILDREN’S DENTAL CARE

The kids’ dental is pretty well covered (general agreement among the group). They (Healthy Kids) just paid for my daughter to have a retainer put in and they paid for almost all of it. They do yearly dental cleanings, they do x-rays, fluoride treatment, sealants – all of it. They do really well with the kids, but it’s once you turn 18 and you’re out on your own if you don’t do what needs to be done, you are screwed. You are not going to have teeth by the time you are 30. (Plymouth, female)

“The only problem with the kids dental that I have seen is if when an emergency comes up or if you miss a visit you have to pay $50 if you miss that visit and you can’t be seen again until you have that $50.” (Plymouth, female)

“And they won’t transfer your records to another provider until your bill is cleared” (Plymouth, female)

<Specific anecdote about child dental emergency –described extensive work done in Concord; “Plymouth couldn’t help us, because of the seriousness of the infection.”> (Plymouth, female)

The lack of oral surgeons in the area is a problem (Meredith, male)


April 18, 2011

APPENDIX II “We are lacking in some of the specialty areas. I have to go to Concord or further to see an allergist and my daughter’s orthodontist is in New London.” (Plymouth, female)

“I’ve had to go to Dartmouth to see an orthopedic surgeon for my daughter. You have to take her to Lebanon or Concord or somewhere else.” (Plymouth, female)

“There is a dental office in Meredith, but they say they can’t do oral surgery there. They can refer you to somebody either to Laconia or there is a place in Center Harbor. But they are very few – hard to come by.” (Meredith, male)

“If you are an adult, you can go to NH Technical Institute and get free or very cheap dental services by students. They are very slow however and it takes multiple appointments to go through the process, but it’s free.” (Ashland, male)

“Another big thing is prostate cancer. There is nobody in this area. We have been having to run around like chicken’s with their heads cut off trying to find somebody. Have to go all the way to Dartmouth, or Massachusetts, or Concord or something. There is nobody in this area that deals with prostate cancer. It’s ridiculous.”

“That’s the only thing about Speare. Speare is good at what they do, but they don’t really cover a lot of things; they are very limited.”

They don’t have a lot of specialists (unidentified).

Lakes Region General is pretty limited too. This area also is severely lacking in neonatal intensive care. (Plymouth, female)

We have no Level 1 traumas, we have no NICU’s. (Plymouth, female)

“Speare is a critical care hospital, like Franklin or Laconia, so they only see critical and emergencies.” (Plymouth, female)

FACILITATOR ASKS QUESTIONS ABOUT REFERRAL COORDINATION AND COMMUNICATION . . .

Depends on who is doing the referrals. Some of the offices are really good at making sure there is communication between the patient, primary doctor and the specialist. Other places it is like you have been handed off. (Plymouth, female)

Tenney Mtn Internal Medicine – it takes them weeks just to connect you with the specialist, literally, sometimes months. And it’s ridiculous when you are in a bad situation. And also even the hospital takes hours – you go in the emergency room and you have a problem, wait 3 or 4 hours and will get to you. It’s like, OK I’m bleeding to death could you please hurry up, its’ ridiculous. (Ashland, female)

REDIRECT TO FOLKS WHO HAVE NOT SPOKEN


April 18, 2011

APPENDIX II <shared specific anecdote that also questioned quality of care – took a week to diagnose strep throat>

“One thing I am a little disgusted with in this area is their lack of help for people who are drug addicts. There is nothing here. And contrary to what Genesis says – that they have someone there helping them – my daughter went there, she was right in the middle of services and the woman just left and dropped her. I won’t tell you the repercussion of it, but it just left her hanging. There was nobody around. I had to drive her all the way to Dartmouth. I personally can’t do that. That’s a lot of gas. And the detox is a whole 30 days. I’m sorry, my daughter needs more than 30 days. <more specific anecdote essentially describing dual diagnosis – MH/SA>. There is nothing around here that can handle both MH and SA services simultaneously.” (Plymouth, female)

“They should be handing off cases, not dropping cases. Somebody who has a drug issue can’t afford the trouble that is going to be caused by being dropped suddenly with no warning.” (Plymouth, female)

“My daughter had gone to Horizons and she owed them money. And they kept saying well you’ve got to pay this. She doesn’t have any money and I certainly don’t have any to give her. So because of that she got no help and she went back down here and back to her old tricks.” (Plymouth, female)

3. Are you aware of anything new or different being done in our community in the past five years to address health-related issues?

a. Are there any new or different services or resources available to you or your family that were not available five years ago?

Question Summary: A few participants discussed ‘Community Care/Health Access as a new and beneficial service. “They have a prescription program too. If it weren’t for them, my husband would probably be dead . . . . I have never been more grateful for anything in my life.” However, only 3 of 18 participants indicated that they were aware of this financial assistance program. Other participants mentioned Mid-State and the facilities at Boulder Point as something new that they were aware of. Other services mentioned included the Plymouth Regional Clinic, Family Planning, early intervention services through Lakes Region Community Services Council, a new sleep center, and food assistance.


Community Care (NH Health Access) through Speare Memorial Hospital. You can get health insurance and it is fairly easy. You can take it with you to the emergency room, to the OB/GYN office, to Mid-State. You get a laminated card. You can get a listing of where you can use it. It helps at Genesis. (Plymouth, female)

“What is it?” (Plymouth, female)

Also just opened new clinic up there on the cliffs – Mid-State, Boulder Point (Ashland, female)


April 18, 2011

APPENDIX II Orthopedics up there is pretty good, so is vision. (Plymouth, female)

“There is also a clinic downstairs (Plymouth free clinic) on Tuesday nights with a sliding scale. But you can only be sick on Tuesdays (general laughter).” (Thornton, female)

“There is a new sleep center in Plymouth which is kind of nice, because my husband always has to go to Concord.” (Plymouth, female)

FACILITATOR ASKS AGAIN ABOUT HEALTH ACCESS – How many people are aware of the Community Care/Health Access program?

<most people not aware; only about 3 of 18 indicated that they knew about it> “No idea”, “Not a clue”, “I have been on state assistance for a year and this is the first I’ve heard of it”, “what is the medical access part of it, I am not familiar with that?”

“They have a prescription program too. If it weren’t for them, my husband would probably be dead. Heart medicine is insanely expensive and I couldn’t get his insurance any more. They paid for his medicine. I have never been more grateful for anything in my life.” (Plymouth, female)

“To sign up for Community Care you just go to the hospital main entrance at the emergency entrance and you ask for Stacy Lembo and she signs you up.” (Ashland, female)

She makes the cards right there in her office. (Plymouth, female)

“I am covered through the state, but I have to pay a spend down. So if I want to go to Genesis, I have to pay a $150 spend down. I’m like, I want to go back to Genesis because I like it, but I don’t have $150 to give to them.” (Plymouth, female)

Hannaford and Walmart both have $4 for 30 day prescriptions and $9.99 for up to 90 days. There is no sign-up either. They have a list and you have to tell the doctor. (Thornton, female)

FACILITATOR PROMPTS TO THINK OF OTHER TYPES OF HEALTH-RELATED PROGRAMS OR RESOURCES THAT ARE NEW

“They have family planning downstairs which is awesome. I took my daughter and we sat there for 3 hours, because they wanted her to be scared. They asked a bunch of questions. But they don’t charge teenagers for any birth control methods.” (Thornton, female)

“My daughter goes to Lakes Region Community Services. She sees an early intervention educator who comes into the home and helps her with her speech and all that. It is a really good program. They are really amazing and they do a fantastic job. My daughter has progressed a lot since she has been seeing them. The only problem is that the service only goes up to age 3 and then the school system takes over. It should be extended until the age at which kids actually start kindergarten.” (Plymouth, female)


April 18, 2011

APPENDIX II “There is a referral program from the early intervention service to the school and (in my experience) they do a smooth transition. But the parent also has to immerse yourself in the record that is compiled at the early intervention to make sure that is passed along and the contact info is always with you and anyone who needs it. In this world, everybody has to have a release now.” (Campton, male)

“I agree with that. They (Lakes Region Community Services) helped my daughter quite a bit and they need somebody else like that around here. The speech therapy at school is not helping her at all.” (Plymouth, female)

“I think this relates to health and that’s the fact that there are good places to get food around here for free. I know of 2 really good food banks in the area and also if you have a child that is 5 or under, you can get free food from the WIC program. I am assuming everybody does that, but if they don’t know about that it is right here in this building. Because of our finances we don’t have a lot of money for food. I don’t think we have spent a dime for food in the last 2 years. We get EBT which is food stamps, we go to 2 food banks, and we get WIC and that covers just about everything we need. It’s amazing. We don’t spend any money for food. I wish they had something like that for gas (general laughter). Then we’d be all set. We’d be golden.”

4. What new programs, services or strategies or enhancements to existing programs, services or strategies would you suggest for addressing our most pressing health or healthcare issues?

Question Summary: Participants discussed the need for low cost recreational and exercise programs for children, but also for adults. The concept of a Community Center similar to the Meredith Community Center was raised by several participants. Both of these needs were also related to the need for more child care options for families, particularly to assist working families during the summer and school vacations. Transportation assistance for medical services was also mentioned as a need by several participants, although others noted being aware of resources to assist with transportation.


“Another thing is medical transportation.” <shared an anecdote related to not having a vehicle; eventually got assistance through senior center, what if I didn’t have that option?> (Ashland, female)

If you have health insurance (participant means Medicaid), they have voucher transportation. There is an 800 number you can call and they will pick you up and drive you to the doctor. (Thornton, female)

Case management through Genesis is extremely helpful including help with transportation. (Plymouth, female)

Speare Memorial Hospital can help you with a ride. (Thornton, female)


April 18, 2011

APPENDIX II Need more low cost programs for kids, like sports and group activities. (Plymouth, female)

“They need an after school youth center here.” <general agreement on this> (Plymouth, female)

<anecdotal description of a youth program in Arizona> (Plymouth, female)

The Kanc Rec Dept. up in Lincoln has a good sports program for kids like soccer. Some of the programs like karate and gymnastics you have to pay for, but it’s pretty good. (Lincoln, male)

An indoor swimming pool would be good for the kids – kids like to swim and helps to keep them healthy. <general agreement> (Ashland, female)

The college has a pool that anybody can use and they have open gym in the summer. (Plymouth, female)

“The motel off exit 27 in Campton has a pool and they make it open to the public.” (Campton, male)

Need more advocating and better management at homeless shelters. Every case there is different, but they treat you all the same. Need better social workers who have more empathy or who have better advice to give you. (Plymouth, female)

“The one that is right here was just made about 5 years ago. Used to be downtown Plymouth. It was quite sad. My mother was in it.” (Plymouth, female)

“There are programs around for kids, like dance studios and sports programs, but have you looked at the prices? Like the cost to get a kid into football; even if you are renting you are talking hundreds of dollars.” (Plymouth, female)

“I think we need one place like a community center. A youth center – different than the teen center. Need an actual community center that would have a variety of programs for younger kids and families – after school programs, summer camps, all of that in one building. Like the community center in Meredith – their community center rocks.” (Plymouth, female)

“This doesn’t relate to children, but in my case I have chronic pain. I know there are a lot of people around here that do. I’m supposed to stretch and do conditioning exercises and the state paid me to go all the way to Dartmouth and spend a month up there getting all this help because they wanted me to go back to work. I couldn’t go back to work anyway, but then they send you home and you are supposed to keep up the exercise. The stretching is fine to keep up, but try and find a way to exercise – weights or treadmill and all this – they have the gyms, but I can’t afford it. If I could have access to some of that – the equipment – I won’t get rid of my pain, but I could ease it a little a bit. I’m not the only one out there and nobody can afford it . . . . There is nothing in the area where you can go in and have someone guide you along the steps so that you don’t hurt yourself. That would really help and I know a lot of people in the same situation. Since they put in the pain clinic, there has got to be quite a few people up there.” (Plymouth, female)


April 18, 2011

APPENDIX II “It would make sense if they added that into the Medicaid or Healthy Kids type thing where at least even if it’s just a discount or X amount of visits – some way to work it in so that you get some sort of gym membership – because that would decrease the amount of health care they would be covering, because we would be improving our health.” (Plymouth, female)

“That’s right. We have nowhere to go to do it.” (Plymouth, female)

Child care up in Lincoln – the summertime through the rec dept you can get scholarships or grants – but it is 9 to 3, five days a week for the first part of the summer. Right now, it’s April vacation and my daughters are out of school and there is no place for them to go. (Lincoln, male)

“It’s the same here.” (Plymouth, female)

“It’s hit or miss. There are some areas that are better with the day care situation. Like the Meredith Community Center steps up and the do a lot of full-time or part-time camps during school breaks.” (Plymouth, female)

“Plymouth Parks & Rec also does some things during school vacations.” (Plymouth, female)

“The summer program is 9-3 for 5 weeks.” (Plymouth, female)

5. On a scale of 1 to 5 where 1=Poor and 5=Excellent, how would you rate the accessibility of health care services in the community? What thoughts or issues came to mind when you gave this rating?

Question Summary: A plurality of participants rated accessibility as a 3 on a scale of 1 to 5, although 4 participants rated accessibility lower and only rated it higher. In general, participants discussed frustrations with long rides to services not available locally, long wait times in the waiting room, and some miscommunications with pharmacies. Selected Comments (not a complete transcript): Rating of 4 – 1 participant

Rating of 3 – 6 participants

Rating of 2.5 – 1 participant

Rating of 1 – 3 participants

“Up in Lincoln it is a 1”

“Laconia is about a zero or a 1”

“My daughter had her first doctor’s visit today. When we went first when as new patients, they were good about it. And she was seen today on an emergency basis, and she was seen right away. So I had a good experience. The doctor was at Mid-state – the pediatrician.”


April 18, 2011

APPENDIX II “The pediatrician at Mid-state is awesome.” (Plymouth, female)

“I don’t have any problems getting an actual appointment. But they always tell you to arrive 15 minutes early which I do. But then I wait on top of that at least another 40 minutes to actually be seen and then they see you for a few minutes and then just go ahead and schedule you for another appointment. That has happened a few times this month already. They are over-booking, because they are trying to accommodate and they do things that they can’t accomplish.” (Plymouth, female)

“I took my daughter over to a pediatric doctor at Dartmouth. Everyone says Dartmouth is one of the best hospitals and I believe that. But the doctor didn’t have the notes from my daughter’s pediatrician. She faxed it over there, but the doctor (at Dartmouth) never got to look at it. We weren’t even in the doctor’s office 10 minutes. We drove all the way to Dartmouth because her pediatrician referred her to Dartmouth. She had all of the paperwork that she needed, but the doctor never looked at the paperwork and we were in there for 10 minutes. I’m like, you aren’t helping me anyway. This isn’t doing anything to help her.” (Plymouth, female)

“We had a similar experience for my daughter’s orthodontist. It’s like a 3 hour round trip ride for a 5 minute visit.” (Thornton, female)

<anecdotal story of miscommunication between doctor and pharmacy> (Ashland, female)

<another anecdotal story regarding pharmacy – an emergency Rx for an elderly family member – similar miscommunication; waiting for Rx; “definitely a lack of communication between doctor’s office and pharmacy”> (Meredith, male)

“You don’t wait very long at Hannaford” (Plymouth, female)

“Hannaford is pretty good” (Plymouth, female)

FACILITATOR SUMMARY: So in general, your rating has to do with frustrations with long rides, long wait times in the waiting room, and sometimes pharmacies aren’t very reliable? (general agreement)

6. On a scale of 1 to 5 where 1=Poor and 5=Excellent, how would you rate the quality of health care services in the community? What thoughts or issues came to mind when you gave your rating?

Question Summary: With a rating of 4, nearly all participants rated the quality of services in the community higher than accessibility and two participants rated quality as a 5 (excellent). Some participants made distinctions between their physicians (“I love my doctor”) and their interactions with nurses and other office staff.


Rating of 4 – general, near unanimous sense of the group


April 18, 2011

APPENDIX II Rating of 5 – 2

“I’d say a 5. I love my doctor” (rating of 5) (Plymouth, female)

“I’d say a 4. I have had good experiences.” (Plymouth, female)

“The people at Genesis lack in what you might call bedside manner. I think the individual people that work there are good at what they do, but the people who work for the office there are very lacking in people skills. Not at all fun to deal with”.

“Sometimes it feels like they are just trying to get you out as fast as they can” <general comment, not specific to any particular agency>

“The nurses seem to be lacking, but the physicians seem to be more attentive. The physician is amazing, but you spend a lot more time with the nurses than the physicians.” <general comment, not specific to any particular agency> (Plymouth, female)

7. In general, do you think people in this area enjoy a high quality of life? Question Summary: Participants discussed the physical environment, community safety and relaxed, peaceful communities as positive factors influencing quality of life and contrasted these factors positively with other areas of the country. The recent renovation of Pease Public Library was described as an important factor contributing to the quality of life in the area. Some participants discussed the poor economy and financial difficulties as factors negatively influencing the quality of life.


“Up where I live, it is what you make it. A lot of people don’t have a lot of money, but we are up in the White Mountains and there is a lot of stuff you can do that doesn’t cost money. Or you can sit inside all day and not do anything, so it is what you make it.” (Lincoln, male)

“My neighborhood is fairly quiet too. It is a very relaxed area. We live near the woods, so in the good weather in the summer I will pull out my hammock and just sit there and read for a while. It is a very peaceful area. You can just sit there and relax.” (Meredith, male)

“It just depends on what you make of it. Your definition of a high quality of life - mine could be different than anybody else. I think some people do, but the economy doesn’t make it easy to do anything that you might want to do.” (Plymouth, female)

“You can do stuff that doesn’t cost much money, but when you are working like crazy to make what little money you do it takes a lot of time away.” (Plymouth, female)


April 18, 2011

APPENDIX II “If you got children with this economy it’s almost impossible. I make the best of it too. I have a huge play yard and I take them to the playground, but that’s about all you can do with them. I actually take them up on Saturday’s to the Mid-state parking lot. Nobody is there and I bring their little trikes and let them run around. It is what it is.” (Plymouth, female)

“We do enjoy a fairly high quality of life because we can do things like that. There are a lot of other places where you would be afraid to take kids, because there is just too many people – I don’t know how else to say it. Other places there is a lot of crime, but around here there is a relatively low crime rate. I don’t know why that is, but I just get that impression that around here that is one of the main things we enjoy . . . . I just think we live a pretty good life around here in a lot of respects that we don’t even really appreciate until you go somewhere else. Like I have a lot of friends and relatives in the New York and New Jersey area and it’s totally different down there. We are so much better off. You have to watch your kids 24-7 down there.”

FACILITATOR SUMMARY: So people tend to appreciate the environment and community safety (general agreement). Anything else?

I really appreciate the Pease Public Library. There are people everywhere who have a negative outlook on life and do drugs and are just on this destructive path. But the Pease Public Library was just redone and it’s really nice. They have kids programs and the whole family can go there and enjoy it. (Plymouth, female)

The college is opening a skate park. That’s going to be great. My kids are dying for that. (Plymouth, female)

8. Finally, if you were given 2 million dollars to spend on any one thing that you believe would contribute to improved health of our community, what would you want to spend the money on?

Question Summary: Discussion focused on the need to invest in enhanced early learning services including sustaining Headstart and expanding Kindergarten hours. Other participants returned to the discussion of the need to subsidize participation in youth sports and other youth activities for lower income families. Finally, there was some discussion of the need to expand the capabilities (additional specialties) of the health care system (Speare Memorial specifically mentioned). Another participant noted the realities of what can be sustained in the area, but discussed the expectation that basic services should be more readily available and specifically mentioned general dentistry for children.


“I would keep the HeadStart program going.” (Plymouth, female)

“I am with her.” (Plymouth, female)

“Longer hours (for headstart).” (Plymouth, female)


April 18, 2011

APPENDIX II “I would do a definite improvement on the day care system.” (Thornton, female)

“We need learning centers instead of day care. There is a learning center in Thornton – the Mad River Learning Center – where kids can start at age 2.” (Plymouth, female)

Need a full day schedule; that’s more like a school schedule. (Thornton, female)

“I would put it more toward extended day for kindergarten (plymouth elementary). My grandson is in the extended day and it costs $120 a month. That was a little mix up. When they told us about it, they never told us that it was going to cost anything. The children in kindergarten actually go to school less hours than the Headstart. It seems pointless to send them longer hours to Headstart and shorter hours for kindergarten when they have to learn so much for first grade. I would have to split the money between Headstart and Kindergarten.” (Plymouth, female)

“I definitely agree with the Kindergarten. It is a huge area of importance.” (Plymouth, female)

“I would invest in extracurricular activities. Like we discussed earlier how much equipment and program costs are for sports or dance. It would be like a special fund for families who can’t afford to buy the equipment; for kids who want to join these activities but their parents can’t afford it.” (Meredith, male)

“I have had 5 kids who have all gone through school. I didn’t have the money (for the programs), but if you ask there are so many people that have scholarships or equipment lending programs.” (Plymouth, female)

“A lot of people do donate equipment for like soccer or skiing even.” (Lincoln, male)

“I would put the money toward expanding Speare Memorial’s capabilities – make it more like Dartmouth in Plymouth so you don’t have to go so far. If something really bad were to happen are you really going to have the ability to concentrate to drive all the way to Dartmouth. If there was somewhere close that had specialty care, it would be a lot safer situation, less stressful, and a lot better if you can visit your family and not have to worry about how to I get home or where do I stay.” (Ashland, female)

“I just wanted to bring up a point about context regarding medical services. One thing that is for sure that everyone has said and I have been there – having to go to Concord just to get a child’s cavity filled. But it is a matter of scale. There are certain levels of medical services that it’s sort of a no brainer – they should definitely be brought up to that level for all access. But when you talk about medical specialists, the amount of money that person receives to be full-time in one particular area, I’m not sure that could happen here, but it is obviously something that is a need. There are basic services that are lacking even if you have insurance – I had to go to Concord to get my daughter’s cavity filled. I think that is a little bit silly.” (Campton, male)

THANKS TO PARTICIPANTS - END

Appendix III Service Providers Focus Group Notes

Page 1 of 5

The Centtargeted gwith socifocus groCenter. Agaps, awafor improparticipator associa

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Page 2 of 5

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Page 3 of 5

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Page 4 of 5

Question Sparticipannatural ensports for

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HP up 11

DIX III mong ed

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Page 5 of 5

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DIX III e

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Appendix IV Local Faith Leaders Focus Group Notes

Page 1 of 7

The Centtargeted gleaders ingroup waUniversalhealth stthoughts were inforecorded

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Selecte

“I susspecifcomminsura

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in any repor

ts: The focusgreater Plym

nd others (thr

eneral, do yd, good, fai

tion Summary: noted that thal health cov

at many resid

ed Comments (

spect that thefic employmmunity withoance do- like

ess to mental heant to seek out sessions [before

rural commuoing somewh

AL NH HEAL

LOCAL

mmunity healommunity munity prior toby the Com

hip. A core d gaps, awarunities for imheir participarts or associa

s group partmouth area. Tree participan

you think tir or poor h

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verage. A parents are self-

(not a complete

ere a lot of pent that migh

out health inse get a yearly

ealth care is notmental health their coverage r

unity it is harhere for coun

APPE

LTH PARTNER

L FAITH LEAD

OCTOB

lth needs assmembers. A fo

o a regularly mmunity Hea

set of quesreness and improvement. ation was voluted with thei

ticipants conTwo participnts) joined th

QUESTION

the peoplehealth?

s felt that grerating was dticipant note-employed or

transcript):

people in the ht provide inurance that dcheckup, or

t anywhere neacare they mightruns out].”

rder to be annseling, it is h

ENDIX

RSHIP – COMM

DERS - FOCUS

BER 14, 201

essment inclfocus group w

scheduled lolth Institute tions asked impressions

The focus untary, confiir responses i

sisted of 5 fpants were inhe conversati

NS & COMM

e in our com

eater Plymoutdue to inaccesed that one rer do various

community nsurance. I sudon’t do the follow up wi

ar where it shout need because t

nonymous [whard to be dis

X III

MUNITY HEALT

S GROUP NOT

11

luded the facwas conductocal clergy asand was helabout perceof existing group lasted

fidential and tin any way.

faith leaders n attendance ion late.

MENTS

mmunity a

th residents assibility of heeason for po“odd” jobs t

that don’t hauspect that thregular thingith a specialis

uld be. Even ththey know that

with mental hscreet about

Cl

APPTH ASSESSME

TES

cilitation of fted on Octobssociation mld at the Staeptions regaservices an

d 60 minutesthat their nam

(pastors, defor the dura

are in exce

are in fair to ealth insuranor or lack ofto make a livi

ave health inshere are thosgs that those st for any pro

hose with insurat they might on

health sessionthat.”

CNHHlergy Focus Grou

October 14, 20

PENDIXENT

focus groupsber 14th with

meeting. The arr King Uniarding commnd programss. All particimes would n

eacons, reveration of the

ellent, very

good healthnce and poor f health insuring.

surance…or e in the of us with

oblems.”

ance and jobs anly be able to go

ns]. Here if yo

HP up 11

X IV

s with h faith

focus tarian

munity , and ipants not be

rends) focus

y

h.

rance

are o for

ou

Page 2 of 7

“I hadcouldabout

One pyou cnight

2. Whacomm

Question Swell as mparishionto addresproblems

Selected Co

“I look ata very straddicted spent on

“I had a pand they emergencThe only her. I canthe qualit

3. Are ypast

a

Question Sa positiveand is runfor the prof patientspeak to t

d a person thd see someont the challeng

participant cocan see”, and s.

t do you thmunity?

Summary: Partmental health ners come to s the problem

s unless they

omments:

t the price ofong addictioand are. Thotobacco cou

parishioner wflat out told cy, but there thing it got h

n understand ty of care she

you aware five years

a. Are tor yo

Summary: The change. Then by a social rogram. Chapts at Speare wthe patients i

hat worked ane outside of ges of anony

ommented ththat there sh

hink are th

ticipants idendisorders as them with evm since the eare suicidal o

f cigarettes ton that has ec

ose economiculd be compa

who was delume that you is nothing wher was an apwhy the doc

e wouldn’t ha

of anythin to address

there any nour family

e participantey also notedworker at Spplains knockwant to speakin their own

APPE

t the universthe universitmity in a sma

hat dental cahould be a fr

he most pre

ntified addictthe most prevident addictemergency roor a danger t

oday and it juconomic conc consequencared to things

usional and reought to be

we can do for ppointment actor was frustave gotten if

ng new or ds health-re

new or diff that were

s identified td that the chapeare Memork on patients k to the chapterminology

ENDIX

sity that askedty,” noted onall communi

are is also a pee dental clin

essing heal

tion to alcohoessing issues tion and menoom does noo others.

ust blows mesequences foces reflect ons they could b

eally strugglinable to bringher unless sh

at Genesis fatrated but I sshe were a p

different belated issue

ferent serv not availa

the expansionaplaincy progrial Hospital.doors and as

plain. Chaplai. One partici

X III

d for a mentane participanity.

problem in thnic like the h

lth or heal

ol, methampfacing the co

ntal health prot accept pati

e away…it juor people than the health obuy for their

ng with that.g people herehe is a threataster. The dostill thought person with a

being done es?

vices or resable five y

n of services gram at the hAround eigh

sk if they woains are restriipant noted t

Cl

APPal health refe

nt in response

he communithealth clinic o

thcare issu

phetamines, aommunity. Troblems, but ients with me

st seems to mat just can’t aof their familr families.”

I went with e with a ment to herself ooctor was reashe didn’t ge

a broken leg.

in our com

sources avyears ago?

provided at hospital is onht local faith

ould like to taicted from prthat the Spea


October 14, 20

PENDIXerence so thee to a comme

ty, “a problemon Tuesday

ues facing

and tobacco, They noted th

that it is diffental health

me that tobacafford to be lies. The mon

her to the Ental health or someone eally dismissiveet anywhere n”

mmunity in

vailable to

Boulder Poinly 2.5 years o

leaders volualk. Around 4roselytizing aare chaplaincy

HP up 11

X IV ey ent

m

our

as hat ficult

cco is

ney

ER

else. e of near

n the

o you

int as old,

unteer 40% and y

Page 3 of 7

program the chapl

Selected Co

“It seemsmore of aother serv

4. Whaprogpres

Question Sopportunmental heparishionpsychiatriSpeare Mpresent, t

Selected Co

“I would parishionrecomme

“There arone numbnow…bemight be them.”

“I wish thdo a videoutside o

“I wish th

“When I full. If a ymethampcan I helpThere is n

is not as intelain’s meeting

omments:

s to me that Ma connectionvices at Boul

t new proggrams, servsing health

Summary: Partnities for enhealth and/or

ners access neist, and great

Memorial Hosto be a seriou

omments:

like some kiner…to say thended 2-1-1 a

re universal sber to call to

ecause I don’the first pers

hat our local o consultatiof Genesis are

here was som

talked to Whyoung mom cphetamines, Ip you make anothing now

egrated as prog are not reco

Mid-State Hen or holism inlder Point].”

grams, servvices or strh or health

ticipants comancement. Asubstance us

eeded serviceter capacity fspital’s inabilius limitation.

nd of centralhis is the proas a state leve

suicide hotlino get someont feel any kinson aware of

Genesis hadon with a psye too expens

mething you c

hole Village acomes in forI’d like to be an appointme

w expect send

APPE

ograms she horded in the

ealth has gonn the care you

vices or strrategies wohcare issue

mmented thatAs the first po

se problems,es. They suggfor short termity to care fo

l processing oblem. Who sel resource.]

nes and that kne to tell me tnd of confidef their proble

d one or two ychiatrist in Live for those

could tell a p

awhile ago, thr financial helable to say toent with an a

ding her to AA

ENDIX

has participatpatients’ cha

ne through chu get betwee

rategies orould you sus?

t mental healoint of conta, the faith leagested a localm addiction tor mental hea

administrativshould I take

kind of thingthe best thingence in diagnem. I’m the o

psychiatristsLaconia.” The without insu

person with a

hey had a twlp and I can o her ‘here isaddiction cenA… or Narc

X III

ted in previoarts at Speare

hanges in theen Mid-State

r enhancemuggest for a

lth and addicct for many r

aders desire ml care coordintreatment seralth patients,

ve thing. Onee them to?” [

g, but it woulg to do with

nosing a persoone that need

s. Right now he participanturance.

an addiction p

wo month waitell by lookins a check fornter. Can we cotics Anony

Cl

APPusly. For exae.

e past few yeand the reha

ments to exaddressing

ction servicesresidents sufmore supportnation call cervices. Additiunless a phy

e number I c[Another par

ld be really hthis person ron’s problem

ds to be able

you have to t noted that p

problem.”

it period becng at her thar the grocery talk about yo

ymous.”


October 14, 20

PENDIXample, notes

ears. There is ab facility [an

xisting g our most

s had the greffering with t in helping enter, a local ionally they nysical threat i

can call as a rticipant

helpful to havright

ms or needs bto connect

go to Laconpsychiatrists

cause they wet she is usingstore AND

our addiction

HP up 11

X IV from

nd

eatest

noted s

ve

but I

nia or

ere g also n?’

Page 4 of 7

One partiwho abussound lik

“You wis

“The onlywoman hwere advoher admitlike…to ghad healtwas highefamily the

“If you wensprained an

“I just feel in the comm

One partiadditionapeople co

One partiordered town pers

“Just aboemploymthrough t

One parispoverty c

A participthat don’tis that peboredomare.”

icipant notedses alcohol. H

ke a solution

sh there was

y time I’ve evhad bipolar diocating for htted somewhget that levelh insurance. er for gettingere as advoca

nt to the hospitnkles. Go away

l the standard ofmunity.”

icipant notedally noted, “Ponnected to s

icipant notedto do volunteonal challeng

out everyone ment. They dothe year. Eco

sh is workingclass differen

pant added, “t cost much…ople perceive

m. The proble

d that he wasHe noted, “Sfor me.”

a way to capi

ver been callisorder and h

her…I thoughhere…so they of attentionBecause of t

g psychiatric ates.”

tal and you thoay.’”

of care is differe

d that there iPart of my jobservices in th

d vandalism ieer work in thges that affec

I know has to whatever it onomically th

g with Wholeces.

“We as midd…we go hikine that there am is not a la

APPE

s unable to fio here he is a

italize on the

led in for an her delusionsht this was a y needed a vi

n she needed the level of dcare. Even to

ought you had sp

ent for mental h

sn’t enough tb isn’t necess

he community

issues about he communict the family

two or three takes…One

he area is not

e Village Fam

dle class peopng and to thearen’t other tck of things

ENDIX

nd an open sa year later an

e moment an

emergency its took a religiwoman in p

ideo conferento have thos

difficulty in seo get that lev

sprained your a

health, and it m

time for himsarily getting y.”

a year ½ agoity. He expresituation suc

different thine way or the o

healthy.”

mily Resource

ple perceive te library weethings to do…to do, but a l

X III

short term dend hasn’t do

nd say, ‘what

t was a mentgious nature…pretty good hnce with a psse advocates etting up thisvel of care it w

ankle…would

might not be if

m to be out inpeople into

o at his churcessed concernch as unempl

ngs they do…other they ge

e Center to d

there to be loekly…One of… One of thlack of comm

Cl

APPetox program

one anything…

can I do for

al health eme… Her daughhands. They wsychiatrist inwith her, ands video confewas the resul

they have said,

there was a psy

n the commuthe church, b

ch. The vandn about the ployment.

…a lot of it iet through th

do a project t

ots of things f the problem

he causes of amunicating w


October 14, 20

PENDIXm for his bro…it doesn’t

you right now

ergency- a hter and husbwere trying to Laconia. It fd she probaberence, the blt of having h

‘no we don’t t

ychiatrist availa

unity. He but getting

dals were couparents and th

s self-he day… they

to address

in the area toms with addicaddiction is what those th

HP up 11

X IV other

w?’”

band o get felt bly bar her

treat

lable

urt heir

y get

o do ction

hings

Page 5 of 7

Aexo

“T

“S

[Another

5. On aqual

Wha

Question Sbut that ma small toother regi

6. On aacce

Wha

Question SFor thosecare is “recommunipastoral paffordablparticipanPlymouth

Selected Co

“[Accessi

“What ifER or yo

[Another recorded.

Another partixamples when the individ

There is muc

Socioeconom

participant j

a scale of 1ity of healt

t thoughts

Summary: Parmental healthown with limional service

a scale of 1essibility of

t thoughts

Summary: Parte with insuraeally hard”. Tity and needepsychotheraple rates on a snts felt that sh area.

omments:

ibility] is grea

f you had to pu go into deb

faith leader .]

cipant echoeere people godual activities

ch more to d

mic level affe

oins the con

to 5 wherth care ser

s or issues

rticipants felth care was sevited services,s as needed.

to 5 wherf health ca

s or issues

ticipants felt nce, accessibThey felt thated national hpy practice hosliding scale tservices were

at if you got i

pay for a babbt.”

from the HS

APPE

ed this statemo and walk ars.

do now than t

ects attitudes

nversation.]

re 1=Poor arvices in th

came to m

t the quality overely lackin, the local ph

re 1=Poor are services

came to m

accessibility bility was “gret the solution

health reformoused at Plymto patients. B generally ac

insurance, an

by out of poc

SA joins the c

ENDIX

ment and offeround for fre

there was to

toward fami

and 5=Excehe commun

mind when

of “physical hng (rating of 1hysician playe

and 5=Exces in the co

mind when

was predomeat”, but for n to the prob

m. One particimouth congrBeyond inacccessible geog

nd it’s really h

cket? There a

conversation

X III

ered the NHee, even if the

do 40 years

ily activities.”

ellent, hownity?

you gave y

health care” 1-1.5). One ped a valuable

ellent, howmmunity?

you gave t

minantly drivethose withou

blem was beyipant mentioregational chucessibility duegraphically, e

hard if you d

are no other

n. It is noted

Cl

APPold home da

ey don’t have

ago.”

”

w would yo

your rating

was excellenparticipant coe role in refer

w would yo

this rating

en by health iut health insu

yond the scoponed Grace Curch, as a sere to lack of h

even for thos

don’t.”

options. You

that convers


October 14, 20

PENDIXays and fairs e money to s

ou rate the

g?

nt (rating of 4ommented thrring patients

ou rate the

g?

insurance staurance accespe of the Counseling, arvice that offhealth insuranse outside of

u either go to

sation is bein

HP up 11

X IV as

spend

e

4- 5), hat as s to

e

atus. ss to

a fered nce,

o the

g

Page 6 of 7

“If peopldoctor ev

Another pHanover,

SeM

“Improvenational pto help podrug assisexample icommuni

[Another the conve

One partiresponsibpreventiv

7. Whatlife?

Question Sthey felt aneeded toparticipanHospital engagemecommuni

Selected Co

“Even a b

One partihelping re

One partiperhaps gfocus on

le in the comven if they ne

participant n, “a world-cla

everal echoeManchester w

ed financial apolicy decisiooor people gstance prograif your child ity’s fault.”

faith leader ersation is be

icipant notedbility for healve care.”

t communit

Summary: Parta bus might no be done to nt recounted each day. Thent includingities, and free

omments:

bus you pay

icipant notedesidents get t

icipant desireglobal perspepreventive c

mmunity don’eed to be goi

noted that theass facility”.

d this sentimwas also bene

access to heaon. I actually get health caram. There’s tneeds to be

joins the coneing recorded

d that there nlth. “There ar

ty-level impr

ticipants all anot be financaddress the a story of a

he participantg playgrounde or low cost

a fare for is a

d that churchto the doctor

ed increased ectives could care.

APPE

t have healthng to the do

e community

ment and addeficial.

alth care cannthink that th

re. The doctothe Plymouthevaluated for

nversation. Td.]

needs to be ere a lot of ov

rovements w

agreed that trcially feasibletransportatioPlymouth rets also recoms accessible bt skiing.

an improvem

h’s “extendedr or the hosp

internationaldrive change

ENDIX

h insurance, Ictor.”

y is fortunate

ed that acces

not be handlehe local healtors have slidinh regional clir a learning d

The facilitator

expanded preverweight peo

would you s

ransportatione for the comon problem ssident that w

mmended proby bike or fo

ment over no

d family compital.

l exchanges wes in the deli

X III

I would say t

e to have Dar

ss to hospital

ed at the locath care institung scales. Thinic. Some chdisability. I d

r reintroduce

eventive serviople in the c

suggest for e

n is a problemmmunity, theysuch as bicycwalks from heograms and inoot, commun

bus.”

mmittees” are

within the coivery of healt

Cl

APPthey will not

rtmouth Hitc

ls in nearby C

al level. I thinutions are alrhe hospital hahildren’s careon’t think it’

es the project

vices, as well aommunity. W

enhancing o

m for the comy still felt thacle paths or ver church to nitiatives for

nity gardens in

valuable reso

ommunity. Hth care, such


October 14, 20

PENDIXbe going to t

chcock in

Concord and

nk it is a stateready doing aas a prescripte is free; for ’s the

t and notes th

as more persWe lack

our quality o

mmunity. What something vans. One

Speare Memr increasing yn various

ources for

He noted thatas an increas

HP up 11

X IV the

d

e or a lot tion

hat

sonal

of

hile

morial youth

t sed

Page 7 of 7

8. Finabelieyou w

Question S

Several pfunding fspent by endowme

lly, if you weve would want to sp

Summary:

articipants nofor residents enhancing Spent of a psyc

were given contributepend the m

oted that thewho can’t afpeare Memohiatric positi

APPE

n 2 million e to improvoney on?

ey would creafford care. Serial Hospitalion at the ho

ENDIX

dollars to ved health

ate a “love aceveral particip’s capacity tospital, or hol

X III

spend on a of our com

ccount” or sipants also felo serve the mlding cells/be

Cl

APPany one thmmunity, w

imilar endowlt the fundin

mentally ill, theds for ment


October 14, 20

PENDIXhing that yowhat would

wment to prong could be whrough the tal health pat

HP up 11

X IV ou d

ovide well

tients.

Appendix V Focus Group Facilitator Script

APPENDIX V

Central New Hampshire Health Needs Assessment

Focus Group Guide

Facilitator script: Thank you for taking the time to meet with us today. The purpose of our discussion today is to ask for your thoughts and opinions about how area health and human service organizations can help improve the health and well-being of the community. Information from this focus group will be used by these organizations to develop plans and programs for improving the health of the community. Your responses will not be connected to your name in any way and will be combined with responses of other community members participating in other focus group discussions. To capture your feedback, we would like to record the conversation using both a digital recorder and hand written notes. This is done so that we can be sure that the information you provide is captured correctly. No names or identifying information will be transcribed from the tape or used in any report. Are there any objections to recording the discussion? Great. We’ll keep as close to your regular schedule for the parent education nights as possible, which means we will talk till about 7:15, take a break, and if we have any remaining questions finish those up after the break. Let’s start by going around and quickly introducing ourselves. If you can share your name, what town you live in and for how long you’ve lived in this area, as well as the makeup of your household- if you have any kids, if your parents live with you. I’ll start: My name is Arielle. I live in Manchester NH and I don’t have any kids. I work for the Community Health Institute which provides services to improve the health of communities in New England.

APPENDIX V

1. In general, do you think the people in our community are in excellent, very good, good, fair

or poor health?

2. What do you think are the most pressing health or healthcare issues facing our community? 3. Are you aware of anything new or different being done in our community in the past five

years to address health-related issues? a. Are there any new or different services or resources available to you or your

family that were not available five years ago? 4. What new programs, services or strategies or enhancements to existing programs, services or

strategies would you suggest for addressing our most pressing health or healthcare issues? 5. On a scale of 1 to 5 where 1=Poor and 5=Excellent, how would you rate the quality of health

care services in the community? _____ What thoughts or issues came to mind when you gave your rating?

6. On a scale of 1 to 5 where 1=Poor and 5=Excellent, how would you rate the accessibility of

health care services in the community? ______ What thoughts or issues came to mind when you gave this rating?

7. What strategies or recommendations would you suggest for improving the quality or

accessibility of health care services in this area? 8. In general, do you think people in this area enjoy a high quality of life? 9. What community-level improvements would you suggest for enhancing our quality of life? 10. Finally, if you were given 2 million dollars to spend on any one thing that you believe would

contribute to improved health of our community, what would you want to spend the money on?

THANK YOU VERY MUCH

Appendix VI Community Leader Interview Script

APPENDIX VI Community Leader Name:

Date & Time:

Location:

Interviewer:

Tape Folder #:

Greater Plymouth Area Health Needs Assessment

Community Leader Interview Guide

The Central NH Health Partnership has asked the Community Health Institute to conduct a

community health needs assessment of the Greater Plymouth and Newfound area.

In addition to a series of key informant interviews we are also doing extensive secondary data

collection, several focus groups, and a community survey. Then we’ll be aggregating all the

information we’ve collected to produce an overall assessment, which will serve as the needs

assessment required under community benefits reporting and will help guide the partnership’s and

the individual organization’s activities.

Two quick notes before we start:

1) Nothing you say in the interview will be directly attributed to you by quote or reference in any

reports or documents. We’ll be combining the information with others to produce an overall

assessment report of the community.

2) The entire community we are looking at is the Greater Plymouth and Newfound area, but if you

feel that you can answers the questions more accurately looking at a subset of the area or even larger

region that’s fine too. If you can just let me know how you define “the community” when thinking

about community health so that I can make note of it.

APPENDIX VI 1. In general, do you think the people in our community are in excellent, very

good, good, fair or poor health?

2. What do you think are the most pressing health or healthcare issues facing our community?

3. Are you aware of any promising new efforts being done in our community in the past five years to address health-related issues?

a. Are there any new or different services or resources available to you or your family that were not available five years ago?

4. What new programs, services or strategies or enhancements to existing

resources you would suggest for addressing the most pressing health or healthcare issues you mentioned?

5. Are there other concerns about the local health and human services system

that you feel are being overlooked?

6. On a scale of 1 to 5 where 1=Poor and 5=Excellent, how would you rate the quality of health care services in the community? _____

What thoughts or issues came to mind when you gave your rating?

7. On a scale of 1 to 5 where 1=Poor and 5=Excellent, how would you rate the

accessibility of health care services in the community? ______

What thoughts or issues came to mind when you gave this rating? 8. What strategies or recommendations would you suggest for improving the

quality or accessibility of health care services in your community? 9. In general, do you think people in your community enjoy a high quality of life? 10. What community-level improvements would you suggest for enhancing our

quality of life? 11. Finally, if you were given 2 million dollars to spend on any one thing that

you believe would contribute to improved health of our community, what would you want to spend the money on?

THANK YOU VERY MUCH. Here’s my card if you think of anything else you want to say, or if you need to follow up with me for anything.

Appendix VII Sample Community Survey

PARTNERS Communities for Alcohol and Drug-Free Youth Community Action Program, Belknap-Merrimack Counties, Inc. Genesis Behavioral Health

Mid-State Health Center Newfound Area Nursing Association Pemi-Baker Home Health And Hospice Plymouth Pediatrics and Adolescent Medicine Plymouth Regional Clinic Speare Memorial Hospital Whole Village Family Resource Center

www.cnhhp.org

APPENDIX VII


EARN $$ FOR A LOCAL CHARITY!

Dear Community Member:

The Central NH Health Partnership is working to collect information about the health of your community and we want to hear from YOU.

For each local resident that completes the survey, the Central NH Health Partnership will donate $2 to a local charity in need!

Please take 5‐10 minutes to give us your thoughts and opinions. The survey is completely anonymous. You will not be asked for your name or contact information.

Your opinions on how we can build a healthier community are important!

Thank you very much for your time.

If you have any questions on this survey please call 573‐3341. A summary report of the survey results will be locally available.

Thank you again for your help.

CNHHP Partners

“Your community” can mean different things to different people. For the purpose of this survey, your community can be as big as the Greater Plymouth & Newfound area or as small as your town. Answer the survey questions by thinking about the area you see as “your community”.



APPENDIX VII

11.. What do you think are the most pressing health issues in your community today?

(Check up to 5)

Access to dental health care Youth alcohol & drug use

Access to mental health care Alcohol & drug use

Access to primary health care Smoking/tobacco use

Access to specialty services Please specify: _____________________

Cancer

Access to enough health insurance Asthma

Health care for seniors HIV/AIDS

Mental i l lness (depression, anxiety, etc.)

Sexually transmitted diseases

Alzheimer’s Other infectious diseases

High blood pressure/heart disease Prenatal care

Diabetes Unplanned pregnancy

Poor nutrit ion/unhealthy food Teen pregnancy

Not enough exercise

Other Please specify: ___________________

22.. What do you think are the most pressing safety issues in your community today?

(Check up to 5)

People under the influence of alcohol or drugs

Discrimination based on l i festyle choices or race

Crime Identity theft

Youth crime Being prepared for an emergency

Child abuse or neglect

Safety at public places (parks, streets, etc.)

Elder abuse School violence

Rape and sexual assault Bullying/cyber‐bullying

Domestic violence or partner abuse




APPENDIX VII

3. What services or resources should we focus on improving to support a healthy community? (Check up to 5)

Public transportation Services for persons with disabil it ies

Job opportunities Substance abuse recovery programs

Job training Access to affordable housing

Adult education & learning opportunities Access to affordable food

Parenting support Access to affordable clothing

Quality child care Clean air and water

Youth programs and support Sports and event opportunities

Education in the public schools Arts and cultural events

Support for older adults


4. In the past year, have you or someone in your family had difficulty getting the services you needed?

Yes (continue below) No (skip to question 5 on next page)

4b. If yes, which services did you or your family have difficulty accessing?(Check all that apply)

Primary health care Social/human service agencies

Specialty health care Please specify: ___________________

Drug & alcohol treatment/recovery services

Dental care for children In‐home support services

Dental care for adults

Long‐term care (assisted l iving or nursing home care)

Mental health


Emergency health care



APPENDIX VII

4c. If yes to #4, why was it difficult to get the services you needed? (Check all that apply)

Did not know where to go to get services Had no health insurance

Did not understand how to get the service

Service was not accepting new cl ients/patients

Office was not open when I could go I was turned away

Service I needed was not available Could not afford to pay

Had no way to get there Needed help with paperwork

Waiting time to receive the services was too long

Misunderstanding with staff

Had no one to watch my child Language/cultural barrier

I was not eligible for services

Did not want people to know that I need the service


5. Which of the following programs or services would you or your family use if it was more available in your community? (Check all that apply)

After‐school activities for youth Fitness/exercise program

Childcare Nutrition/cooking program

Adult daycare Weight loss program

Parenting support groups Health education

Family counseling

Lesbian, gay, trans‐gender and bisexual support services

Caregiver support Diabetes support group

Education workshops for parents Mental health counseling

Adult education Drug and alcohol treatment

Job training Drug and alcohol prevention activit ies

Information and referral Stop smoking program

Stress reduction and relaxation classes

Medical services Please specify: ___________________

Community gardening Public transportation




APPENDIX VII

6. What do you think is the best thing about l iving in your community?

7. What do you think is the most difficult thing about l iving in your community?

8. If you could change one thing that you believe would contribute to better health in your community, what would you change?

The fol lowing questions will help us to better understand the characteristics of your community. This information will not be used to identify you in any way.

9. What is your age?

18‐19 50‐64

20‐24 65‐74

25‐34 75 and older

35‐49

10. What is your gender?

Male Female

11. About how many years have you l ive in the Greater Plymouth or Newfound area?

________________ years



APPENDIX VII

12. What town do you l ive in now?

Alexandria Lincoln

Ashland New Hampton

Bridgewater Orange

Bristol Plymouth

Campton Rumney

Danbury Thornton

Dorchester Warren

Ellsworth Watervil le Valley

Grafton Wentworth

Groton Woodstock

Hebron Other

Please specify: __________________

Holderness

For questions 13 & 14, a household is a group of people sharing a home and any income earned with each other.

13. Approximately, what is your annual household income?

Less than $10,000 $50,000‐ $74,000

$10,000‐ $25,000 $75,000‐ $100,000

$25,000‐ $49,000 More than $100,000

14. How many people are part of your household?

________________ people

As a thank you for completing this survey, the Central NH Health Partnership will donate $2 to a local charity in your area.

Please place the completed survey in the near‐by drop‐box, or mail to:

Central NH Health Partnership c/o Community Health Institute, Attn: Arielle 501 South St. 2nd Floor Bow, NH 03304

҉ Thank you ҉

Appendix VIII Towns By Geography

APPENDIX VIII Greater Plymouth Public Health Region CNHHP Service Area Grafton County

Tow

ns

In G

eogr

aph

y Ashland Campton Ellsworth Holderness Lincoln Livermore Plymouth Rumney Thornton Warren Waterville Valley Wentworth Woodstock

AlexandriaAshland Bridgewater Bristol Campton Danbury Dorchester Ellsworth Grafton Groton Hebron Holderness Lincoln New Hampton Orange Plymouth Rumney Thornton Waterville Valley Wentworth Woodstock

AlexandriaAshland Bath Benton Bethlehem Bridgewater Bristol Campton Canaan Dorchester Easton Ellsworth Enfield Franconia Grafton Groton Hanover Haverhill Hebron Holderness Landaff Lincoln Lisbon Littleton Livermore Lyman Lyme Monroe Orange Orford Piermont Plymouth Rumney Sugar Hill Thornton Warren Waterville Valley Wentworth Woodstock

2010 Total Population 23,658 35,054 89,118Data Source: Census 2010

Documents

Central New Hampshire Health Partnership Community Health Needs Assessment 2011