Tri-State community
The Tri-State community includes 10 counties in Kansas, Missouri and Oklahoma.
Table of Contents
PART 1: INTRODUCTION
Executive Summary
The Tri-State Community is a 10-county area that includes three hospital systems: CoxHealth, Freeman Health System and Mercy. This report will present key findings and identify, assess and prioritize top health issues of concern for the Tri-State Community. This is done through a health equity lens. Health equity is defined as making sure every person, no matter their background or circumstances, has the same opportunity to be healthy.
The goals of this report are to provide collaborating partners, community-based organizations and community members with a greater understanding of health needs and of people most affected by poor health outcomes. The Tri-State Community uses a social determinants of health (SDOH) framework to determine broad categories for priority health outcomes and behaviors. This enables individuals and organizations to identify root causes when developing improvement plans, based on feasibility and resources available. By working together, community members and organizations can mobilize resources to have a collective impact on improving health and well-being for all residents in the community.
“Social determinants of health are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning and quality-of-life outcomes and risks.”
- Healthy People, 2030
Service Area
The Tri-State Community is made up of 10 counties across three states. Missouri counties include Vernon, Barton, Jasper, Newton and McDonald. In Kansas: Crawford, Cherokee and Labette. In Oklahoma: Ottawa and Delaware. In the Ozarks Health Commission (OHC), CoxHealth, Freeman Health System, Mercy, Jasper County Health Department and Joplin Health Department represent the Tri-State Community.
Three health systems’ hospitals, in addition to local public health departments, define the Tri-State Community as their service area. This includes the following:
Hospitals
CoxHealth
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Cox Barton County Hospital
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CoxHealth Clinics
Freeman Health System
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Freeman West Hospital
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Freeman Neosho Hospital
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Freeman Fort Scott Hospital
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Freeman Clinics
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Ozark Center
Mercy
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Mercy Hospital Joplin
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Mercy Hospital Carthage
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Mercy Hospital Columbus
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Mercy Hospital Pittsburg
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Mercy Specialty Hospital of Southeast Kansas
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Mercy-GoHealth
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Mercy Clinics
Local Public Health Agencies (LPHAs)
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Cherokee County Health Department
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Crawford County Health Department
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Labette County Health Department
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Delaware County Health Department
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Ottawa County Health Department
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Joplin City Health Department
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Jasper County Health Department
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Newton County Health Department
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McDonald County Health Department
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Barton County Health Department
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Vernon County Health Department
Population overview
The OHC noted several important demographic and population trends within the Tri-State Community. The area is home to 386,399 residents and is an estimated 30% of the OHC region’s total population. From 2010-2020, the population declined by 0.7%. This decline led to concerns about aging populations, job losses, declining tax revenues and shrinking schools and neighborhoods. Hispanic populations had the greatest population increase and White populations had the greatest population decrease in the overall community. Other population changes varied across counties and people from racial and ethnic minority groups.
Of the Tri-State Community population, 53% is classified as rural and 47% is classified as urban. Seven out of ten counties are classified as more than 50% rural. Three of these counties are greater than 99% rural. Residents of the community mostly identify as White (82%), while approximately 17% identify as Black, Asian, American Indian or Alaska Native (AIAN), Native Hawaiian or Pacific Islander (NHPI), some other race or multiple races. The Tri-State Community is home to larger populations of AIAN (5%), NHPI (1%), and multiple race populations (8%) compared to the OHC region, states and national racial and ethnic populations.
Nearly 24% of residents are minors under the age of 18, while approximately 18% are over the age of 65. This means on average the population is older than both the OHC region and the nation. Older residents are more likely to be living with chronic illnesses and require access to more health services. Rural counties account for higher percentages of populations over the age of 65. Further, approximately 58% of residents are age 18-64, which drives the workforce in the community.
Approximately 17% of the total population is living with a disability, which is roughly the same as the OHC region but higher than the national rate of about 13%. This may contribute to access to care difficulties and disparities among community members with disabilities.
Population by age
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Population by race
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Rural vs. urban population
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Populations of interest
Health disparities are the result of inequities rooted in social, racial/ethnic and economic injustice. Communities disproportionately affected by health disparities—such as residents of rural areas, people experiencing poverty, people from racial and ethnic minority groups and older adults—often experience higher rates of chronic illness and worse health outcomes. Utilizing health equity as a guiding priority, root causes of health outcomes were the focus in identifying people from the Tri-State Community who are disproportionately affected by health disparities.
Economic stability
Across the lifespan, people experiencing poverty are at increased risk for poor mental health, chronic disease, higher mortality and lower life expectancy.¹ Children experiencing poverty are at increased risk of developmental delays, toxic stress, chronic illness and nutritional deficits.² Individuals who experience childhood poverty are more likely to experience poverty into adulthood, which creates generational cycles. Community survey results showed the most prevalent challenge for community members not accessing health care and mental health care for children and adults, including access to medication, are financial reasons or cost concerns.
Education access and quality
Not completing high school is linked to many factors that can negatively impact health, including limited employment opportunities, low wages and poverty.³ Factors related to individual students as well as broader institutional factors can affect a student’s ability to graduate.⁴, ⁵ Limited language and low literacy skills are associated with lower educational attainment and worse health outcomes.⁶ High school graduation rates (86%), unemployment rates (4%), poverty rates (18%), and populations with limited English proficiency (2%) are factors that negatively impact the Tri-State Community greater than the OHC region, states, and nationally.
Physical activity
Health care access and quality
Health care access and quality
Inadequate health insurance coverage is one of the largest barriers to health care access and uninsured adults are less likely to receive preventive services for chronic conditions such as diabetes, cancer and heart disease.⁷, ⁸ Another access barrier is the limited availability of health care resources, particularly in rural communities and Health Professional Shortage Areas (HPSAs).⁹,¹⁰ Unavailable or unreliable transportation can also contribute to negative outcomes by limiting access to health care resources.
Neighborhood and built environment
Housing quality refers to the physical conditions of a person’s home and the quality of the environment where the housing is located.¹¹ The Tri-State Community reports approximately 15% of households with one or more severe problems and describes 3.3% of housing units as overcrowded. Poor housing quality and inadequate living conditions, including the presence of lead, mold or asbestos, poor air quality and overcrowding can contribute to increases in chronic diseases and injuries.¹²,¹³
Social and community context
Social and community context
Community relationships are important for physical and mental health and well-being. High levels of social support from family, friends or organizations like churches can positively influence health outcomes through behavioral and psychological pathways.¹⁴ Social isolation is an area of concern for older adults and has led to increases in mortality.¹⁵ Approximately 15% of households in the Tri-State Community include seniors living alone, which is higher than region and state averages, and higher rates of isolated older adults are reflected in counties that are mostly rural.
Rural populations
Residents of rural areas are more likely to experience some of the contributing SDOH factors that impact health and can be compounded by additional barriers, such as availability of transportation and limited access to healthy food. Rural communities also experience SDOH factors in prenatal care, childcare and educational opportunities.¹⁶,¹⁷
Q: "What is your biggest barrier to better health?"
“Affordable insurance.”
“Timely appointments without massive wait times.”
“Difficulty getting appointments.”
“Waiting months for an appointment.”
“Lack of providers in the area.”
- Community Survey Answers, 2024
Health indicator improvements
Over the past three years, the Tri-State Community has made significant strides in improving various health indicators. Notable improvements include:
Insurance coverage
There has been a marked increase in insurance coverage for individuals aged 18-64. In 2019, 20% of adults were uninsured. This decreased to 17% in 2022. Insurance coverage for individuals under 18 fell from 8% in 2019 to 6% in 2022. This improvement is crucial for enhancing access to healthcare services and reducing financial barriers to care.
Women’s health
The rate of mammogram screenings increased from 67% in 2018 to 70% in 2022 for adult females aged 50-74. Mammograms contribute to early detection and treatment of breast cancer, which is vital for improving survival rates. Alternately, opportunity exists in improving access to cervical cancer screening. Tri-State saw a 2% decrease in women aged 21-65 receiving recommended cervical cancer screening. This reflects a rate of cervical cancer (13.3 per 100,000) that is higher than the OHC region, state and nation.
Diabetes screening and management
Enhanced diabetes screening efforts have led to earlier diagnosis and management of diabetes, helping to prevent complications and improve quality of life for affected individuals. Hospital data reports rates of diabetes are lower than region and state rates. Annual A1c testing among Medicare enrollees has been consistently increasing since 2008, with 82% of Medicare enrollees with diabetes receiving their annual exam. With these improvements there are many areas of opportunity for a complex disease such as diabetes. Efforts towards programs and increased access should continue to grow.
Preventable hospitalizations
There has been a reduction in preventable hospitalizations of approximately 5% per year from 2012 to 2021 among Medicare beneficiaries, indicating better management of chronic conditions and improved access to primary care services. However, the Tri-State community reports a higher rate than the OHC region, indicating further opportunity in this area.
Annual wellness visits
The number of annual wellness visits in adults aged 18 and older has returned to pre-COVID-19 pandemic rates. While the overall rate for the Tri-State Community is still lower than surrounding areas at around 73%, there has been significant progress in overcoming some of the barriers caused by the pandemic.
While these improvements are encouraging, it is important to acknowledge that some of these factors are still below state and regional rates and vary in severity across urban and rural areas. However, the positive trends observed suggest that continued efforts and focused interventions can further bridge these gaps bringing us to the health priorities reflected in this report.
Methodology
The Tri-State Community steering committee members—represented by the Joplin Health Department, Jasper County Health Department, Freeman Health System and Mercy—formed a work group to identify priority health issues, analyze quantitative and qualitative data and guide the prioritization process for community partners. Analysis focused on root cause factors associated with health outcomes. Building on the methodology developed by the OHC, the work group began analysis of partner and community survey response data and public health data through a series of meetings from September to October 2024. Methodologies used in survey development and a comprehensive list of comparison tables can be found in the OHC Regional Report. Aggregated public health data, using the SDOH framework, revealed health factors and health indicators that were compared to community feedback and categorized into seven top health issues of concern (cancer, chronic disease, dental care, infectious disease, behavioral health, nutrition and physical activity, and unintentional injury). Health system data was not yet available during the time of this analysis.
Information from the Community Toolbox,¹⁸ National Association of County and City Health Officials (NACCHO),¹⁹ and Association of State and Territorial Health Officials (ASTHO) ²⁰ were used as guides in the prioritization process for assessed health issues. A simplified prioritization matrix was implemented for each identified health issue with size of the problem, seriousness of the problem, feasibility, disparities, available expertise and importance to the community adopted as criteria categories based on the Hanlon Method.²¹ A scoring system of Low (1), Medium (2), or High (3) was utilized and each criteria category was rated with equal importance. A supplemental instruction sheet accompanied the prioritization matrix with additional questions for community partners to consider for each category when scoring identified health issues. Average scores for each criterion were calculated and a final score was developed from the overall average for each health issue.
The Tri-State Community convened a special meeting of the Tri-State Community Health Collaborative (CHC) to assess and prioritize identified health issues through primary and secondary data sources and further incorporate community feedback. Representatives from public agencies, nonprofit organizations, local collaboratives and coalitions, CHC members and community leaders were invited to a hybrid in-person/virtual meeting in Joplin. Based on the seven health issues identified by the work group, contributors convened to further consider top priorities.
Prior to the meeting date, the work group drafted supplemental fact sheets and a summary data table (to provide context surrounding prioritization matrix criteria for each identified health issue) from root cause analysis findings. To provide a comprehensive overview of identified health issues, and to aid in discussion and informed decision making for each evaluation criteria, these additional documents were emailed to all meeting invitees prior to the meeting date. Feasibility criteria was left to community representatives to assess and determine based on their perspectives, resources and capabilities for their respective organizational or individual goals.
On October 11, 2024, 47 community partners and collaborators representing health care, education, public health, libraries, law enforcement, community-based organizations and court systems gathered to discuss and prioritize the top seven identified health issues. Printed copies of supplemental data sheets were provided to participants. Following an overview of the OHC’s methodology for the regional report and presentation of instructions and expectations, work group representatives presented each health issue. They highlighted community input and associated health factors and outcomes in which the Tri-State Community experienced worse rates than the OHC region, state and national rates. Health system data was not available at the time of this meeting and is unlikely to have affected the prioritization results. For each health issue, the presenter facilitated open-forum discussion before moving on. These discussions included two question prompts:
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Does anything from the presentation, notes or handouts stand out to you?
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Do you feel we can do something about this?
Following a final summary and discussion, an anonymous, electronic, live vote—utilizing the established prioritization matrix—elevated the top three health priorities.
PART 2: Community health priorities
Chronic disease
Behavioral health
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Nutrition and physical exercise
Chronic disease
Chronic diseases are broadly defined as conditions that last one year or more, such as heart disease, cancer and diabetes. They require ongoing medical attention, limit activities of daily living or both.²² Chronic disease affects a large part of the population and management is expensive. These conditions require ongoing medical care, medications and sometimes hospitalizations. Limited access to preventive care services and health care resources can negatively affect chronic disease outcomes, particularly for communities experiencing disadvantages because of health disparities. The high needs of managing chronic disease can also affect mental health, leading to conditions such as depression and anxiety.
In the Tri-State Community, heart disease, lung disease, stroke and cancer mortality are higher than the OHC region, states (Kansas, Missouri and Oklahoma) and U.S. rates. Hospital data shows chronic disease or chronic disease indicators in the top 7 out of 10 condition rates, including hypertension, diabetes and heart disease. The community survey did not directly address specific conditions, although feedback from community partners and residents indicated barriers in access to care. Respondents indicated the top three reasons for not accessing medical care as financial, scheduling and insurance. Surveyed community partners also indicated barriers in access to healthy food options and physical activity opportunities, which are contributing factors to chronic disease.
LUNG DISEASE MORTALITY
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The rate of available primary care providers is 74.24 per 100,000 population, which is lower than the OHC region, states and national rates and is insufficient to meet the needs of the Tri-State Community, according to community response. Approximately 14% of residents do not have health insurance, which limits access to care needed to prevent and manage chronic conditions. Of people with lower incomes, about 64% experience low food access, which can contribute to poor nutrition. Housing barriers are also contributing factors to increased rates of chronic diseases and are a significant health factor in the Tri-State Community. Households with structural problems and overcrowded housing situations impact overall health and well-being.
Another major risk factor for several chronic diseases is smoking, and in the Tri-State Community approximately 23% of adults indicate they are current smokers. Further, about 16% of adults report excessive alcohol use. Physical activity is a critical component of chronic disease prevention, and 25% of adults report no leisure time activity. This, along with about 40% of residents not having access to exercise opportunities, shows there are barriers preventing participation in physical activity.
Hospital data shows chronic disease or chronic disease indicators in the top 7 out of 10 condition rates, including hypertension, diabetes and heart disease.
BEHAVIORAL HEALTH
Behavioral health refers to a state of mental, emotional and social well-being and is a key part of overall health. Behavioral health also includes behaviors and actions that affect wellness and is used to describe support systems that promote well-being, prevent mental stress and provide access to treatments and services for mental health conditions.²³ During the prioritization process, mental health and substance use disorders were identified as separate health issues. Through further analysis, findings indicated multiple similarities in contributing factors and populations of focus, so they were combined under the definition of behavioral health for this assessment.
Mental health
Mental health
Mental health is important at every stage of life and has many influencing factors including brain chemistry, life experiences and family history. Mental health is also closely linked to physical health. For example, depression increases the risk of chronic conditions like diabetes, heart disease and stroke. Mental health is not only the absence of a mental health condition, but also the presence of well-being and the ability to thrive. A mental health condition is an illness or disorder that affects a person’s thinking, feeling, behavior or mood. Nearly one out of four adults in the U.S. live with a mental health condition.²⁴ Anyone can face challenges to their mental health, regardless of whether they have a mental health condition or not.
adults 18+ with poor mental health
adults 18+ with poor mental health
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Deaths of despair
death due to suicide, alcohol-related disease and drug overdose
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adults 18+ with poor mental health
Substance use
In the Tri-State Community, behavioral health is an area of concern with multiple contributing factors and barriers. Although the rate of mental health providers in the community is higher than the OHC region, states and national rates, this indicator does not match up with rates of adults with poor mental health (19%) and suicide mortality rates (18.96 per 100,000 population). The differences between counties and disproportionate coverage of mental health providers between rural and urban counties indicates a significant lack of access or accessibility, which was reflected in feedback from the partner and community surveys. While secondary data shows the Tri-State Community as roughly the same or better than the OHC region in most measures of associated factors and outcomes, importance to the community, continuous increase in yearly trends, and significant disparities among contributing factors prioritizes behavioral health as a focused health issue.
Poor mental health can be both a cause and consequence of substance use.
Poor mental health can be both a cause and consequence of substance use. People experiencing poverty also experience increased stress and limited access to resources, increasing likelihood of substance use as a coping mechanism. Higher poverty rates in people from racial and ethnic minority groups, despite only accounting for 17% of the community population, indicates a significant disparity. Lower levels of education contribute due to limitations in job opportunities for people without high school diplomas, creating economic instability. Further, an estimated 4% of students in the Tri-State Community experience homelessness, which significantly impacts education attainment and increases chronic stress. In some communities, there may be cultural acceptance of substance use, making it more prevalent. Social circles and peer pressure can further influence engagement in substance use. Co-occurrence of mental health conditions and substance use disorders creates severe complications for treatment and recovery, especially in areas where availability of resources is limited.
Nutrition and physical activity
Healthy eating, physical activity, adequate sleep and stress reduction are important to achieving optimal health. Good nutrition is important across all life stages and reduces risk for serious health problems such as heart disease, type 2 diabetes and obesity.²⁵ Physical activity is one of the best things people can do to improve their health, and for people with chronic diseases, physical activity can help manage some conditions and complications.²⁶ Nutrition and physical activity also contribute to overall well-being and behavioral health.
adults 18+ with poor physical health
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Adults 18+ with poor or fair general health
In the Tri-State Community, the rate of adult residents with obesity is 34%, which is higher than the OHC region, states and national rates. Primary data from the community indicated time, interest, finances and access as the top reasons not to engage in physical activity or improve nutrition. Secondary data indicates only 60% of the population in the Tri-State Community have access to exercise opportunities, and only 25% of the population has adequate access to healthy food options. Hospital data further indicates a higher rate of disordered eating in the community compared to the region, which could further indicate the severity of food insecurity and lack of nutritional resources. These barriers are greater for people in rural communities, who experience additional barriers related to health behaviors and higher instances of chronic disease.
High cost of living limits access to healthy food and physical activity opportunities by reducing the amount of disposable income for healthy food and recreational activities. The Tri-State Community has limited transportation resources (0% of the population is within walking distance to public transit) and low walkability (7 on a scale of 1 to 20) making it difficult for residents to access areas for physical activity. Less than 30% of the population in the community lives within a half mile of a park. This lack of access is further limited for people experiencing poverty or homelessness and people living with disabilities.
Health insurance coverage is an additional factor that can affect access. Without health insurance, or with inadequate coverage, limited access to health resources such as nutrition counseling or physical therapy can contribute to poor outcomes. Of adults in the community, 20% report poor or fair general health, which can be influenced by poor nutrition and physical inactivity. Behavioral health factors also are a significant driver of maintaining good nutrition and participating in physical activities.
Interconnectivity
These priorities are deeply interconnected, with several overlapping causal factors contributing to their prevalence and impact on the community. Shared causal factors like limited access to care, socioeconomic challenges, behavioral risks (e.g., smoking, substance use), and environmental barriers (e.g., lack of exercise opportunities, food insecurity) emphasize how these interconnected factors contribute to the community’s health needs.
PART 3: Closing Remarks
Conclusion
While this overview of health in the Tri-State Community is not comprehensive, it gives an important glimpse into health priorities reflected in both data and community feedback. The 2025 assessment will be used to inform public health and health care initiatives. These initiatives will be outlined in a forthcoming Community Health Improvement Plan.
Dissemination
The OHC regional report and all community-level reports are available to the public through various channels
Websites
Ozarks Health Commission
www.ozarkshealthcommission.org
CoxHealth
Freeman Health System
freemanhealth.com
Mercy Hospital
Printed copies
Printed copies will be available by request through health care partners and LPHAs. Please refer to organization websites or contact an organization directly
Social media
Mercy Southwest Missouri and Southeast Kansas Communities
Health services available
Ackowledgements
Thank you to Tri-State Community partners and residents for contributing to this assessment through your feedback. Your contributions provide rich context to the vast health care data compiled for this report.
Thank you to the OHC Steering Committee for your collaboration and resource sharing during every step of the CHNA process.
Thank you to the Tri-State Community representatives in the OHC steering committee for your contributions toward data collection and creation of the report.
Citations
¹ Khullar, Dhruv, and Dave Chokshi. “Health, income and poverty: Where we are and what could help.” Health Affairs Health Policy Brief (October 4, 2018). https://doi.org/10.1377/hpb20180817.901935.
² Evans, Gary W., and Pilyoung Kim. “Childhood Poverty, Chronic Stress, Self-Regulation, and Coping.” Child Development Perspectives 7, no. 1 (2013): 43–48. https://doi.org/10.1111/cdep.12013.
³ Magnani, J. W., H. Ning, J. T. Wilkins, D. M. Lloyd-Jones, and N. B. Allen. “Educational Attainment and Lifetime Risk of Cardiovascular Disease.” JAMA Cardiol 9, no. 1 (2024): 45-54. https://doi.org/10.1001/jamacardio.2023.3990.
⁴ Magnani, J. W., H. Ning, J. T. Wilkins, D. M. Lloyd-Jones, and N. B. Allen. “Educational Attainment and Lifetime Risk of Cardiovascular Disease.” JAMA Cardiol 9, no. 1 (2024): 45-54. https://doi.org/10.1001/jamacardio.2023.3990.
⁵ LaVeist, Thomas A., Eliseo J. Pérez-Stable, Patrick Richard, Andrew Anderson, Lydia A. Isaac, Riley Santiago, Celine Okoh, Nancy Breen, Tilda Farhat, Assen Assenov, and Darrell J. Gaskin. “The Economic Burden of Racial, Ethnic, and Educational Health Inequities in the US.” JAMA 329, no. 19 (2023): 1682-1692. https://doi.org/10.1001/jama.2023.5965.
⁶ Gulati, Reeti K., and Kevin Hur. “Association Between Limited English Proficiency and Healthcare Access and Utilization in California.” Journal of Immigrant and Minority Health 24, no. 1 (2022): 95–101. https://doi.org/10.1007/s10903-021-01224-5.
⁷ Lazar, Malerie, and Lisa Davenport. “Barriers to Health Care Access for Low Income Families: A Review of Literature.” Journal of Community Health Nursing 35, no. 1 (2018): 28-37. https://doi.org/10.1080/07370016.2018.1404832.
⁸ Horne, Gabrielle, Amber Gautam, and Dmitry Tumin. “Short- and Long-Term Health Consequences of Gaps in Health Insurance Coverage among Young Adults.” Population Health Management 25, no. 3 (2022): 399-406. https://doi.org/10.1089/pop.2021.0211.
⁹ Rural Health Information Hub. “Healthcare Access in Rural Communities.” Rural Health Information Hub. 2024. https://www.ruralhealthinfo.org/topics/healthcare-access.
¹⁰ Southwest Rural Health Research Center. Rural Healthy People 2030. College Station, TX: Texas A&M University, 2023. https://srhrc.tamu.edu/documents/rural-healthy-people-2030.pdf.
¹¹ Swope, Carolyn B., and Diana Hernández. “Housing as a Determinant of Health Equity: A Conceptual Model.” Social Science & Medicine 243 (2019): 112571. https://doi.org/10.1016/j.socscimed.2019.112571.
¹² Marí-Dell’Olmo, Marc, Ana M. Novoa, Lluís Camprubí, Andrés Peralta, Hugo Vásquez-Vera, JordiBosch, Jordi Amat, Fernando Díaz, Laia Palència, Roshanak Mehdipanah, Maica Rodríguez-Sanz, Davide Malmusi, and Carme Borrell. “Housing Policies and HealthInequalities.” International Journal of Health Services 47, no. 2 (2017): 207-232. https://doi.org/10.1177/0020731416684292.
¹³ Boch, Samantha J., Danielle M. Taylor, Melissa L. Danielson, Deena J. Chisolm, and KellyJ. Kelleher. “’Home is Where the Health Is’: Housing Quality and Adult Health Outcomes in the Survey of Income and Program Participation.” Preventive Medicine 132 (2020): 105990. https://doi.org/10.1016/j.ypmed.2020.105990.
¹⁴ Strine, Tara W., Daniel P. Chapman, Lina Balluz, and Ali H. Mokdad. “Health-Related Quality of Life and Health Behaviors by Social and Emotional Support: Their Relevance to Psychiatry and Medicine.” Social Psychiatry and Psychiatric Epidemiology 43, no. 2 (2008): 151-159. https://doi.org/10.1007/s00127-007-0277-x.
¹⁵ Holt-Lunstad, Julianne, Timothy B. Smith, Mark Baker, Tyler Harris, and David Stephenson. “Loneliness and Social Isolation as Risk Factors for Mortality: A Meta-Analytic Review.” Perspectives on Psychological Science 10, no. 2 (2015): 227-237. https://doi.org/10.1177/1745691614568352.
¹⁶ Rural Health Information Hub. “Rural Health Disparities.” Rural Health Information Hub. 2022. https://www.ruralhealthinfo.org/topics/rural-health-disparities.
¹⁷ Rural Health Information Hub. “Social Determinants of Health.” Rural Health Information Hub. 2024. https://www.ruralhealthinfo.org/topics/social-determinants-of-health.
¹⁸ Center for Community Health and Development, University of Kansas. “Assessing CommunityNeeds and Resources.” Community Toolbox. 2024. https://ctb.ku.edu/en/assessing-community-needs-and-resources.
¹⁹ National Association of County and City Health Officials. Guide to Prioritization Techniques. Washington, D.C.: NACCHO, 2013. https://www.naccho.org/uploads/downloadable-resources/Gudie-to-Prioritization-Techniques.pdf.
²⁰ Association of State and Territorial Health Officials. “Public Health Assessment.” Association of State and Territorial Health Officials. 2024. https://www.astho.org/topic/public-health-infrastructure/assessment/.
²¹ National Association of County and City Health Officials. Guide to Prioritization Techniques.Washington, D.C.: NACCHO, 2013. https://www.naccho.org/uploads/downloadable-resources/Gudie-to-Prioritization-Techniques.pdf.
²² Centers for Disease Control and Prevention. “About Chronic Diseases.” Centers for Disease Control and Prevention. 2024. https://www.cdc.gov/chronic-disease/about/index.html.
²³ Centers for Disease Control and Prevention. “About Behavioral Health.” Centers for Disease Control and Prevention. 2024. https://www.cdc.gov/mental-health/about/about-behavioral-health.html.
²⁴ Centers for Disease Control and Prevention. “About Mental Health.” Centers for Disease Control and Prevention. 2024. https://www.cdc.gov/mental-health/about/index.html.
²⁵ Centers for Disease Control and Prevention. “About Nutrition.” Centers for Disease Control and Prevention. 2023. https://www.cdc.gov/nutrition/php/about/.
²⁶ Centers for Disease Control and Prevention. “About Physical Activity.” Centers for Disease Control and Prevention. 2024. https://www.cdc.gov/physical-activity/php/about/.