There are numerous factors that contribute to the health of a community and to the individuals who reside there. Social health, environmental health, and availability and access to health services all play a crucial role. Mortality and morbidity rates also serve as a measure of health, but the concept of health cannot be so narrowly defined. Moore County data was used in this description due to the lack of specific health data for the community of Robbins; however, Robbins data was utilized when available.
The overall adjusted mortality rate in Moore County for 1993-97 was 7.23 per 1,000, compared to North Carolina's adjusted mortality rate for 1993-97, which was 8.47 (State Center for Health Statistics (SCHS), 1999). Adjusted mortality rates refer to rates which would be expected if the age, sex, and race composition of Moore County were the same as the standardized rate of North Carolina. These rates are used so that a more accurate comparison of county and state can be conducted. The county followed the same trends as the state regarding the leading causes of death, which were cancer and cardiovascular disease (CVD). As noted in Table 2, mortality rates from 1993-1997 for motor vehicle injuries, suicide, and female breast cancer were higher in Moore County than in all of North Carolina (SCHS, 1999).
In 1991, Governor Jim Hunt created The Task Force on Health Objectives for the Year 2000 (North Carolina Governor's Task Force on Health Objectives for the Year 2000, 1992), in response to the national initiative of Healthy People 2000. Table 2 lists the top 10 causes of death in Moore County, as compared to North Carolina and the Healthy Carolinian Year 2000 Objectives.
Table 2. Leading Causes of Mortality and Adjusted rates for Moore County & North Carolina Per 100,000, 1993-1997
| Causes of Death | Moore County | North Carolina | Healthy Carolinian's 2000 Objectives |
|---|---|---|---|
| Heart Disease | 206.0 | 251.6 | 248.9 |
| Cancer | 188.3 | 197.4 | 204.7 |
| Cerebrovascular Disease | 65.5 | 65.8 | 62.4 |
| Female Breast Cancer | 31.6 | 27.2 | |
| Chronic obstructive lung disease | 31.1 | 38.3 | 25.5 |
| Pneumonia and Influenza | 28.4 | 30.2 | |
| Motor vehicle deaths | 24.6 | 20.8 | 29.6 |
| All other unintentional injuries | 19.7 | 19.8 | |
| Suicide | 14.6 | 12.3 | 10.6 |
| Diabetes | 9.0 | 22.6 | 20.3 |
| Chronic liver disease and cirrhosis | 7.3 | 9.0 |
Source: Moore County Health Department, 1999
Source: North Carolina Governor's Task Force on Health Objectives for the Year 2000, 1992
The majority of Moore County adjusted rates were below both North Carolina rates and the Healthy Carolinian's Year 2000 Objectives, indicating that Moore County is successfully working towards achieving better overall health. However, cerebrovascular disease and suicide rates were above the state average and the Healthy Carolinian's Year 2000 Objectives, which implies a need for more preventive physical and mental health services.
Looking at mortality across race and gender, CVD was the leading cause of death for white males and females, as well as non-white females. It was also the leading cause of death in North Carolina (Moore County Health Department, 1999). Over half the deaths from CVD in North Carolina occur among women. Although the rates of CVD in North Carolina are declining, it is still a serious health concern, especially within Moore County. In addition, cancer is the number one cause of death for non-white males in Moore County (Moore County Health Department, 1999). For non-white males, the leading types of cancer were trachea, bronchus, prostate and lung, giving this population a cancer mortality rate almost 31% higher than the state (Moore County Health Department, 1999). White males were subject to the same types of cancer but with lower mortality rates, and CVD was the number one cause of death in that group. Both white and non-white females were susceptible to the same types of cancer: trachea, bronchus, breast and lung; however, the mortality rates differ dramatically between the two groups. White females exhibited cancer mortality rates that were 3% lower than the state, while non-white females had a cancer mortality rate 10% higher than the state (Moore County Health Department, 1999).
Causes of death other than disease are also concerns in Moore County. The overall rate of death due to injury, which includes suicide, homicide and motor vehicle accidents, was 74 deaths per 1000 in 1993-95 (DEHNR, 1997). It should be dually noted that although Table 2 cites the overall rate of motor vehicle accidents as 27.0, the rate for those ages 15-24 is significantly higher at 49.8 (DEHNR, 1997). For children, unintentional injuries are a leading cause of death and disability. According to the Moore County Health Department, from 1988-1997, 37 children died from unintentional injuries. Over a third of these deaths resulted from motor vehicle accidents.
The causes of death in Moore County are presented in Figure 1 with a clear illustration of the prevalence among the leading causes.
Figure 1. Causes of Death In Moore County by Percent, for 1993-97
Source: SCHS, 1999
Moore County had an infant mortality rate of 13.6 per 1000 in 1998, nearly 43% higher than the state's rate of 9.3. Although this rate approached the Healthy Carolinian's Year 2000 Objectives (7.4), there was a disparity when those rates were broken down by race (North Carolina Governor's Task Force on Health Objectives for the Year 2000, 1992). For white babies, the rate was 4.1 per 1000, which was lower than the Healthy Carolinian's Year 2000 Objectives, but for non-white babies, the rate was 44.4 per 1000 (SCHS, 1999), placing the non-white infant mortality rate significantly above the Healthy Carolinians 2000 Objectives of 8.7 per 1000 (Moore County Health Department, 1999). Based upon this information, it is apparent that infant mortality for minorities is an issue that needs attention in Moore County.
Disease rates for Moore County were below the state rates for the following communicable diseases: AIDS, gonorrhea, syphilis, hepatitis B, pertussis, salmonellosis, and chlamydia. Table 3 compares the Moore County disease rates with the North Carolina disease rates. Based on the Healthy Carolinian's Year 2000 Objectives, all of the Moore County rates are still above the state goals.
Table 3. Disease Case Rates per 100,000, 1992-1996, unless otherwise noted
| Health Indicators/Diseases | County Rate | NC Rate |
|---|---|---|
| Cancer a | 403.4 | 359.7 |
| AIDS b | 4.4 | 11.55 |
| Gonorrhea c | 155.23 | 363.37 |
| Tuberculosis b | 9.18 | 8.35 |
| Syphilis rate c | 8.22 | 22.34 |
| Hepatitis B d | 4.06 | 4.79 |
| Chlamydia rate (per 10,000) *c | 10.8 | 23 |
| Hepatitis A d | 1.88 | 1.89 |
| Pertussis d | .31 | 2.02 |
| Salmonellosis d | 10.32 | 16.66 |
| Lyme disease d | .31 | 1.08 |
Source: DEHNR 1997 Note: a=1991-1993, b=1991-1995, c=1993-1995, d=1992-1996
*=Moore County Health Department, 1999
The incidence rate of cancer in Moore County is of significant concern, since it is the only morbidity rate that is considerably above the state's. The four most prevalent forms of cancer, listed in Table 4, were female breast, lung, colorectal, and prostate. All were above the state's rates, except for lung cancer.
Table 4. Age-Adjusted Cancer Incidence 1991-1993 Per 100,000
| Type of Cancer | County Rate | State Rate |
|---|---|---|
| Female Breast | 123.1 | 108.5 |
| Lung | 53.9 | 56.2 |
| Colorectal | 43.1 | 41.3 |
| Prostate | 193.6 | 137.3 |
Source: DEHNR, 1997
Primary medical services are provided within Robbins for residents, but for other services, residents must travel either to places outside of Robbins, including: Carthage, Pinehurst, or Southern Pines in Moore County, or to Troy, in Montgomery County.
Robbins has one family practice physician, one adult nurse practitioner, two dentists, one optometrist, and one pharmacist. Dr. William Bell, who practices family medicine, has served the Robbins area for more than twenty years. He reports a patient load of 60-75 people a day, does house calls, takes walk-ins, and is on-call 24 hours a day (W. Bell, personal communication, November 4, 1999). Dr. Bell accepts Medicaid, Medicare, and uninsured, self-pay patients. In 1998, the residents brought forth a petition, to the town board, requesting another medical provider. In response, St. Joseph of the Pines, a long-term medical care facility in Pinehurst, established Robbins Medical Center in June of 1998. The center employs one adult nurse practitioner, Vicki Cooke-Erdoes. This addition has provided an alternate provider option for persons over 18, but there is still a need for a provider trained in pediatrics (V. Cooke-Erdoes, personal communication, November 4, 1999).
Table 5 lists the rates of providers to population for both the state and county level. There are significantly fewer primary care providers in Moore County than the state average. However, this does not necessarily indicate a higher patient load or an under-served population, because many people may leave the county to receive care.
Table 5. Number of Providers to Population, 1997
| Providers | North Carolina | Moore County |
|---|---|---|
| Primary Care Physicians | 1:1387 | 1:1667 |
| Primary Care Physicians plus Extenders | 1:1098 | 1:1166 |
| Registered Nurses | 1:118 | 1:86 |
| Dentists | 1:2488 | 1:2299 |
Source: DEHNR, 1997
The Moore County Health Department is located in Carthage, 12 miles from Robbins. This facility offers numerous clinical, environmental, and health education programs, all with a focus on prevention. These services include: immunizations, family planning, pregnancy testing, maternity services, child health services, adult health services, breast and cervical cancer preventive services, communicable disease programs, including testing and treatment for sexually transmitted diseases, neuromuscular/orthopedic clinic, and Women, Infant and Children's Nutritional Services (WIC). Some of these services are free, while others have income guidelines or a fee based on a sliding scale (FirstHealth of the Carolinas, 1999).
The eleven member Moore County Board of Health acts as the policy making body for the Cdirection of the local health director, the health department staff puts these standards, along with state and federal criteria, into action (FirstHealth of the Carolinas, 1999). County Health Department, and sets the health standards for the County. Under the direction of the local health director, the health department staff puts these standards, along with state and federal criteria, into action (FirstHealth of the Carolinas, 1999).
FirstHealth of the Carolinas is a not-for profit healthcare network, formed when Moore Regional Hospital and Montgomery County Hospital merged in 1995, which provides an array of healthcare services to the residents of this region of North Carolina. Because Robbins is located in the northwest corner of Moore County, residents may access FirstHealth services in either Moore County, or in Troy, which is in neighboring Montgomery County (FirstHealth of the Carolinas, 1999).
Moore Regional Hospital, located in Pinehurst, is an acute care, not-for-profit hospital that serves as the referral center for a 15-county region in the Carolinas (FirstHealth of the Carolinas, 1999). This hospital is 23 miles from Robbins, has a capacity of 397 beds, and is the top referral of the primary care providers in Robbins (W. Bell, personal communication, November 4, 1999). Moore Regional provides comprehensive medical services. The hospital has 11 operating rooms, a full laboratory and pharmacy, 19 bays in the emergency room, and 67 intensive care beds (S. Phillips, personal communication, November 16, 1999).
In addition, Robbins residents also utilize Montgomery County Hospital, located in Troy, NC. This hospital is 27 miles from Robbins, and has a total of 37 primary care beds, 51 long-term care beds, and an emergency department with 24 hour physician coverage (FirstHealth of the Carolinas, 1999).
FirstHealth has primary care medical clinics in Carthage and in Troy; both provide services such as well child checks, adolescent care, adult medicine, and geriatrics. Both clinics accept Medicare and Medicaid, as well as self-pay, uninsured patients. From October 1, 1998 to September 30, 1999, the Carthage clinic served 9000 patients (D. Blinkman, personal communication, November 11, 1999.
In October of 1998, FirstHealth opened a dental care center in Southern Pines, 26 miles from Robbins. A second dental clinic opened in Troy in January of 1999. These dental centers treat patients age 18 and under. Their services are limited to Medicaid and N.C. Health Choice recipients, as well as children whose families are 200% below the Federal poverty level. They provide basic dental services on a regular basis, and more intensive dental procedures as needed (L. Smith, personal communication, November 16, 1999).
FirstHealth has a mobile van that covers an eight county area, offering free mammograms, prostate cancer screening, diabetes screening, cholesterol checks, and blood pressure checks. From September 30, 1998 to October 1, 1999, the van provided 12,439 screenings. Data on the number of Robbins residents served was unavailable. The van comes to areas in response to requests from churches, businesses, community organizations, and for special events. In Robbins, the van comes to Davis Community Center at least once a month, and to other service areas in town as requested (P. Lariviere, personal communication, November 13, 1999).
St. Joseph of the Pines, located in Pinehurst, offers long-term skilled nursing care to the elderly and the infirm. They recently partnered with Duke University to offer home health care to Robbins and other communities in North Carolina (Office manager, St. Joseph of the Pines, personal communication, November 5, 1999).
There is a Moore County Emergency Medical Services (EMS) base located in Robbins that responds to calls for persons in need of medical assistance. They will provide immediate medical assistance, transport individuals to area hospitals, and serve as support for the Robbins Fire Department. There are 13 paramedics on call 24 hours a day, covering a ten-mile radius (B. Strickland, personal communication, November 12, 1999).
The fire department, located in Robbins, provides emergency safety to a ten-mile radius of Robbins. There are 25 volunteer members, and they are all on-call 24 hours a day (D. Brown, personal communication, November 16, 1999).
The primary care providers in Robbins both accept Medicaid, Medicare, and uninsured, self-pay patients. The recent initiation of the children's health insurance program, "North Carolina Health Choice for Children," which provides coverage for any N.C. resident under the age of 19 who does not qualify for Medicaid, has enabled many who were not previously eligible for insurance to get coverage. In 1996, fourteen percent of the population in Moore County was uninsured, compared to 12.8% for the state (North Carolina Health Care Reform Commission, 1996). In Robbins, 5% of Dr. Bell's patients are uninsured; additionally, 11.17% of the Robbins residents seen at Moore Regional are uninsured, as well as 76% and 40.3% of the Robbins residents seen at the FirstHealth dental clinics in Troy and Southern Pines, respectively (S. Phillips, personal communication, November 16, 1999).
In January of 1999, the Northern Moore Family Resource Center (NMFRC) surveyed, by mail, 2800 residents of Northern Moore. The 211 respondents ranked medical resources as the second most important need of the community; specifically, a doctor and an additional pharmacy were mentioned (M. Shamberger, personal communication, September 29, 1999).
Moore County does not have a public transportation system available, so Robbins residents must secure their own transportation in order to access services provided outside of the town. Moore County provides transportation service to some county agencies. They will also transport individuals that are Medicaid or Medicare recipients. Although this service fills a need, it excludes persons that are not Medicaid or Medicare recipients (R. Cook, personal communication, November 5, 1999).
In response to this barrier, the NMFRC offers a transportation service to residents of northern Moore County. This service is available to anyone at no cost, and it can be used to meet daily needs. This service is entirely staffed by volunteers, for a limited amount of hours during the week. They will transport individuals anywhere within a 30 mile radius of Robbins (M. Shamberger, personal communication, September 29, 1999).
The growing population of Hispanics in Robbins has posed a challenge to the service providers. The communication barrier frustrates the residents and the providers who are attempting to meet their health needs. There is no Spanish speaking medical provider in Robbins or in Carthage, and Spanish speakers often rely on their bilingual children to translate (V. Cook-Erdoes, personal communication, November 4, 1999). There is an interpreter available at the Moore County Health Department; however, there is not one at the Moore County Department of Social Services (B. Robinson, personal communication, November 5, 1999). FirstHealth of the Carolinas has a bilingual staff member at their dental clinic in Troy; otherwise, they rely on the BellSouth Language Line, and information sheets written in Spanish, to help them meet the need. There are Spanish speaking medical providers available at Moore Regional and Montgomery County Hospitals (P. Lariviere, personal communication, November 13, 1999).
Many social factors contribute to the health and well being of Robbins' residents. Robbins is a relatively small community with numerous opportunities for citizens to support each other. Churches are a common means of community involvement for residents. According to the secretary of the First Baptist Church of Robbins (personal communication, November 15, 1999), there are nearly 100 members, from ages 20 and over, who actively participate in community activities at their church alone. Three major churches, including First Baptist, Tabernacle Methodist, and Elise Presbyterian, are committed to the Robbins Area Christian Ministry. The Robbins Area Christian Ministry, governed by a board of directors, operates a food bank and thrift store. The proceeds are funneled back into the community to residents in need of funds (First Baptist Secretary, personal communication, November 15, 1999).
The first annual Health Fair, sponsored by Saint Joseph's of the Pines, was held November 13, 1999. Screenings for diabetes, blood pressure, cholesterol, glaucoma, vascular disease, and prostate cancer were offered, along with free influenza immunizations. A Children's Health Fair is also annually hosted by the First Baptist Church. This is a well-attended event, sponsored by the Moore County Health Department, that provides immunizations for children (First Baptist Church Secretary, personal communication, November 15, 1999).
Residents of Robbins who are in need of mental health services, or assistance with substance abuse issues, are referred to clinics and treatment centers outside of Robbins. Sandhills Center for Mental Health (SCMH) is the main site in Moore County for such treatment. In addition, the Northern Moore Family Resource Center offers an Alcoholics Anonymous (AA) program, as well as family and individual counseling. There are also several AA groups located in Southern Pines, Pinehurst, and Aberdeen (Office Manager, SCMH, personal communication, December 3, 1999).
Sandhills Center for Mental Health offers adult and adolescent mental health counseling, and substance abuse counseling. They provide individual, group, and psychiatric therapy. The center is partially funded by the State government. Options for payment include private insurance, Medicaid, and a sliding scale. Recovery Associates and Pinehurst Treatment, both private centers, also provide substance abuse treatment (Office Manager, SCMH personal communication, November 15, 1999). Recovery Associates is a fee for service center in Southern Pines that offers drug and alcohol rehabilitation and testing for a small number of Robbins residents (Office Manager, personal communication, December 3, 1999). All centers noted that they work with Robbins residents but current statistics on Robbins were unavailable.
Crime and violence has a tremendous impact on the health of a community. Robbins has experienced a decrease in criminal activity and violence since the town has implemented a proactive approach to crime prevention in the last few years (T. Brady, personal communication, November 4, 1999).
According to North Carolina statistics, the crime rate was 41 per 1000 people in Moore County in 1995 (North Carolina Office of State Planning, 1997). The county rate decreased between 1997 and 1998, from 40.8 to 34.5 per 1000, according to the N.C. State Bureau of Investigation (1998).
Data from the Robbins Police Department shows that there was an 18% decline from 1997 (2470) to 1999 (2024) in criminal activity in the town. These activities include shoplifting, vandalism and trespassing. There was also a 20% decrease in accidents from 1997 (80) to 1999 (60). From October 1997 to October 1999, the number of investigations, arrests, citations, and accidents all increased slightly. Between October 1998 and 1999, vandalism resulted in 25% (34) of the total number of offenses. A quarter (26) of the charges were for robbery, larceny, or theft; 14% (14) were for assault; and 13% (13) were against residents who were Driving While Intoxicated (DWI). From October 1997 to 1998, 64% (76) of the offenses were related to vandalism, burglary, or larceny. The percentages of charges for crimes were distributed similarly in 1999 (Robbins Police Department, 1998).
Civic Organizations Organized civic clubs, including Kiwanis and Lions Club, are active in Robbins. The Girl Scouts and Boy Scouts of America also have troops in Robbins. There is a Veterans of Foreign War (VFW) Post as well (A. Moore, personal communication, November 15, 1999).
Seniors Every Monday through Friday seniors can meet at the Davis Community Center, for lunch and activities. The program, run through the Moore County Department of Aging, provides lunch for the 30 seniors that come to the Center; volunteers also deliver lunch to the homes of 28 elderly Robbins residents (E. Haywood, personal communication, November 15, 1999).
Parks and Recreation The Moore County Department of Parks and Recreation offer several programs to boys and girls in Robbins. These include baseball, softball, basketball, cheerleading, and dance classes. There is also a countywide softball team available for adults. The NMFRC also sponsors a girls and boys soccer league in the fall and spring. (M. Shamberger, personal communication, September 29, 1999).
In 1997 the town of Robbins applied for and received a grant to build a community park; construction of the Milliken Community Park was completed in the summer of 1999 (A. Moore, personal communication, October 19, 1999). The park has a picnic area, a swing set, tennis courts, basketball courts, a baseball diamond, and a track.
Additional Resources The Northern Moore Family Resource Center was established in Robbins in 1994 and programs began in 1995. The purpose of the NMFRC is to encourage and support the development of a strong community, by matching the resources available with the identified needs. The NMFRC is strongly committed to literacy and education; there is a family literacy program that works with parents and their young children, as well as GED and ESL classes. One of the most unique services provided is an occupational therapy program for children. The Executive Director feels that the services at NMFRC adequately reach a broad scope of the population, and new programs are routinely under evaluation (M. Shamberger, personal communication, September 29, 1999).
Recently, the controversy surrounding the reallocation of water districts across Moore County has become a concern for its residents. This issue has become more heated in the aftermath of the dissolution of Moore County Water and Sewage Administration (MoWASA). This is a pivotal concern for the county planning office, where they are trying to prepare for the inevitable population growth of the coming decades. As Moore County continues to grow, the allocation of water resources is extremely urgent and salient. The majority of residents were against the county wide water system, and voiced two main concerns. Primarily, they argued that a countywide water system would promote growth in Moore County. Residents feared that such growth would overwhelm their rural county. Secondly, they were concerned that the proposed water system would create an unfair tax burden to all residents, while primarily benefiting those in the southern part of the county (Gilkeson, 1999).
It is important to consider the historical context in which this controversial subject was born. In 1976, the county sewage system was restructured with no opposition. In 1977, a countywide water system was proposed as the next logical step. However, the county's officials decided against a $12 million dollar bond from the federal Environmental Protection Agency to create the water system. The rationale for turning down this option was that the residents thought that it would promote "undesirable growth" (Gilkeson, 1999). Now 23 years later, the issue arises again with the same level of controversy. Qualitative Data Collection
In this examination of the factors that influence Robbins' health, several key issues stand out. Robbins is a community that is working to meet the needs of its residents. However, several barriers stand in the way of achieving optimal health and well-being. Infant mortality continues to be a serious concern that needs to be addressed, especially within minority populations. Lack of transportation to health care facilities and language barriers make obtaining health care a challenge for certain populations. Although Robbins must overcome these barriers, the community has acknowledged these needs in an effort to ameliorate overall health.
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