Identification of Community
Kentucky is a state with approximately 4,413,457 citizens according to the United States Census in 2014. 38,728 of these people reside in Floyd County (American FactFinder, 2014). Floyd County was founded in 1800 by Colonel John Floyd. Floyd County has a total area of 396 square miles. It is a traditionally democratic county.

Population Economic Status Assessment
The population of Floyd County Kentucky is ~38,728 (Kentucky Health Facts, 2015). Per 1,000 female Floyd County citizens, there are approximately 64.6 births per year. Per 100,000 people in this state, there are approximately 1,135.7 deaths annually in Floyd County. For every 100 females there are 96.7 males. For every 100 females age 18 and over, there are 95 males. The average household income is $28,221, compared to the state of Kentucky which is $42,248 and compared to the United States which is $51,425. 28.9% of Floyd County citizens are living below the poverty level (American FactFinder, 2013). 98% of people living in this county are white. 1.1% are black, and all other ethnic groups are less than 1% (American FactFinder 2013).

Neighborhood/Community Safety Inventory
After speaking with Shannon Hall (Fire Chief of Left Beaver Rescue Squad in Floyd County Kentucky), I was able to answer many of the questions posed on the Neighborhood and Community Safety Inventory. Shannon has worked for the Floyd County and Left Beaver Rescue Squad for over 20 years, and is both an EMT and a firefighter.

The most prevalent air and water pollution issue in Floyd County stems from ironically, the source of most of our citizens’ livelihood, which is coal. Coal mines and coal tipples are plentiful in this county, and even though they’re not as active or successful due to the recent “War on Coal”, we still have many people employed at these facilities and are still being affected by the runoffs into our streams and the pollutants these coal preparation plants put off into the air we breath. Natural radiation is another unfortunate side effect of coal mining. Coal ash is considered by some in the scientific community to be even more radioactive than nuclear waste (Mara Hvistendahl, 2007). According to Hvistendalh, “the fly ash emitted by a power plant—a by-product from burning coal for electricity—carries into the surrounding environment 100 times more radiation than a nuclear power plant producing the same amount of energy.” (Hvistendahl, 2007). Cancer is one of the leading causes of death in Floyd County, specifically lung cancer. COPD and asthma sufferers are more common than not in this county. We breath so much of the coal ash and have so many heavy smokers in the area, it is really no surprise that such illnesses are so prevalent. Weather in this county, like most counties in Eastern Kentucky, is dependent upon the season. The summers range from comfortable temperatures to dangerously hot, with temps soaring above 103 degrees. Fall and Spring are generally mild and uneventful, other than the flash flooding or freak tornado outbreaks which are rare but often disastrous to a county with more mobile homes than brick and mortar buildings. Tornado shelters are not a staple in this county, and most of the homes that aren’t mobile were built during the coal boom 50 or more years ago, and are quickly deteriorating even without the added detriment of strong winds. Winters in Floyd County, although often beautiful, present their own unique health and safety hazards to the people of this county. The roads are winding and dangerous on even a nice sunny day, when adding ice, snow and freezing temperatures to the mix they become even more hazardous. Four-wheel drive vehicles are basically a staple if one plans to spend their winters here. A large percent of residents live in hollows or on mountains, which makes commuting to and from work a life threatening venture during harsh winter weather.
Many Floyd County residents, particularly the elderly, often find themselves faced with the daunting task of finding transport to the local Emergency Room during winter, as the weather is sometimes so bad that even four-wheel drive automobiles cannot make it to them in these hollows and hills. Local EMS teams are frequently forced to respond to “Life Threatening Emergencies Only” due to the inability of the ambulances to trek the roads to these people’s homes. A feeling of shortness of breath for a COPD or CHF sufferer is sometimes not a life or death matter, but to that patient it feels differently. It is a common occurrence for chronic respiratory disease patients to be admitted to the local hospital before an upcoming snow or ice storm, so that they will not be stranded at home without oxygen access in the event of a power outage. There is only one lake in Floyd County, which is well known as “Dewey Dam”. In the summer months this lake is a popular attraction for teenagers and families as a popular fishing, boating and swimming hole. Drowning deaths at this lake are fortunately not a common problem, with approximately 1 drowning death occurring every 3 years, and are usually tied to alcohol use or blatant safety negligence. One more common safety hazard in this county is the ever growing population of wild deer and elk that live in our many hills and mountains. These large animals often cause motor vehicle accidents in their attempt to cross major and minor roadways in Floyd County. In 2012, police agencies in Kentucky reported 2,766 deer-related crashes, causing 106 injuries with no reported driver fatalities – a decrease from 2011 when 2,972 crashes with 148 injuries and three fatalities were attributed to deer (Floyd County Times, 2013).

Cultural Assessment Tool I used the cultural assessment tool to examine the different cultural attitudes in Floyd County through interviews and research. In this county, there is very little range in cultural attitudes. The vast majority of citizens of Floyd County are Christian, Southern Baptist to be exact, Caucasian, and fit well with the “mountain folk” persona. Less than 1% are black, and other minority groups make up even less than that. God and family are the top priorities for most. Strong work ethics and pride in self reliance are increasingly less common, but when people do have this belief, they tend to have it very strongly.
Citizens in this area speak of a fondness and pride for attending church every Sunday, usually with their immediate and extended families being in the same congregation. They have a strong faith in God which has been instilled in them since birth. I spoke with 32 year old Samantha Jo Stumbo, a member of McDowell First Baptist Church in Floyd County. When asked how she felt about aging health, she stated “I feel like God wants us to do what we can to take care of ourselves, but after a certain point its just up to him what happens to us. I’m not in good health, but I do have God on my side and I know that he has had my life planned out since before I was even born. What ends our life is up to God, not up to us.” Samantha is referring to her recent COPD and hypertension diagnoses, and extinguishes her cigarette after she’s done speaking. Her statement, and actions, encompasses the feeling of most of our community members.
As evidenced by my conversation with Mrs. Stumbo, it is not only the elderly who suffer from chronic diseases and/or have unhealthy lifestyles. In fact 35% of adults 18-65 in Floyd County are smokers, 59% are overweight, 30% meet the criteria to be considered obese, and 36% rate their overall health status as “less than good” (Kentucky Health Facts, 2015). Only 13% of Floyd County residents are age 65 or older.
Many times in practice as a Registered Nurse, I have had patients who are non-compliant in their prescribed medication regimes, and will pray to God for rescue when their oxygen level becomes dangerously low. It is a startling feeling to see these same patients smoking on hospital campus the next day, after we have corrected their acute problems. It would be inaccurate and unfair to portray all citizens of Floyd County in this manner, but being on the front lines of health care of my small community, it is a saddening truth about the vast majority, and a harsh reality that I see firsthand everyday. Religion plays a large role in this, as it seems to give some people an excuse to take their health less seriously, because they feel that God is in control of their outcomes either way.

Disaster Assessment and Planning Guide In the event of a major disaster in Floyd County, the most likely to be affected age group would probably be the elderly population. A large percentage of seniors in this community rely on portable oxygen tanks in order to have adequate gas exchange in their daily lives due to COPD, tobacco abuse, lung cancer and asthma. If a disaster were to occur that made access to emergency care difficult, it would mean dire consequences for these people. Inability to refill oxygen tanks or to get to the local hospital are two complications that we unfortunately would not be adequately prepared for. If the disaster manifested itself in the form of a strong tornado, the most common injury would likely be blunt force trauma due to lack of appropriate shelter. As previously stated, the most common type of housing in Floyd County is mobile homes, which offer little to no protection from tornadic winds. There are very few underground basements, and no public tornado shelters available.

Windshield Survey
I used the Windshield Survey to take a closer look at the physical features of Floyd County, and analyze how these features could possibly be either a detriment or positive aspect in relation to the health of the citizens. The houses in Floyd County are for the most part single or double wide mobile homes, constructed from 2x4 wooden planks and sheetrock anchored into on a concrete foundation. This is a detriment to health during the spring storm season, as these types of homes are easily damaged by high winds. Some less common types of homes are found sporadically throughout the county, and are two story, large brick homes or A-frame type homes constructed from pine wood. The business facilities, schools and post offices are brick and mortar buildings built many decades ago, and are starting to fall apart and need frequent remodeling and updates. Solar panels and windmills are not currently used in any buildings or homes in this county. Large front and back yards are commonly found in Floyd County, but well tended yards are just as commonly found as neglected ones. Central heat and air and modern plumbing are widely used, but many poorer families rely on kerosene heat and box window air conditioners to combat the cold or heat. These people are at a higher risk for carbon dioxide poisoning and house fires as well. Homes without modern conveniences such as heat, air conditioning and modern septic systems are not common but can certainly be found in this community. Citizens of this county mostly travel by car, truck or by foot. There are no forms of public transport such as buses or subways. Big Sandy Transport is a taxi-van service that only caters to the elderly who have medicaid or medicare services, and only transports them to and from medical appointments. The youth often walk beside the road to get to the local park or a friends house, which is dangerous due to the lack of sidewalks. Floyd County is without a doubt a rural county. Open space is scarce due to the many rolling hills of Appalachia. Lush green trees and grass are more often found than open fields or long stretches of vacant areas. Discarded trash and old tires pollute the ditches and creeks beside the roads, and even though it is cleaned up regularly by the inmates of Floyd County Detention Center, it seems to re-accumulate very quickly.
The roadways are mostly two lane roads, with faded yellow and white lines in need of refreshment. A large percentage of citizens live in hollows, and the roads in the hollows are usually in poor condition, if they are paved at all. Potholes and broken asphalt are common, and youths first learning to drive are taught how to avoid or handle these hazards since they are found so frequently. Creeks and streams are found in nearly every neighborhood in Floyd County, which run into the Big Sandy River in our county seat called Prestonsburg.
There are several public parks where baseball and t-ball games are played in the spring and summer months. Teenage boys often congregate at these parks in the evening hours to play pickup games of basketball. Another type of person that frequents these public areas are drug dealers and buyers, which presents danger to the children who are also at the park. Deputy sheriffs have recently increased patrol of public parks in Floyd County in order to deter this.
There are green metal signs that indicate the names of the towns, such as “Drift”, “McDowell”, “Minnie”, “Wheelwright” and “Prestonsburg” to name a few. There is one Wal-Mart in Floyd County, and one Food City. There are smaller, family run grocery stores scattered throughout the county. Gas stations are plentiful for such a small county. Southern Baptist churches are very common, approximately 4 for each small town in Floyd County. There is one Mosque which is located in the county seat, Prestonsburg, which has been the center of much controversy throughout the years following 9/11. There are very few, if any, Muslim families in Floyd County. Most of the members of the mosque travel from surrounding counties for their religious services. There is one currently used train track in Floyd County, but the remains of tracks from long ago during the heyday of coal production are easy to find.
To really shop for clothing or higher end items in Floyd county, one must travel to Prestonsburg or Pike County, though the selection is limited. Most people travel 2 hours to the closest mall in Huntington, West Virginia. There are three hospitals in Floyd County: McDowell Appalachian Regional Healthcare, St. Joseph Martin, and Highlands Regional which is located in Prestonsburg. All of these hospitals stay busy due to the many COPD and cancer patients, drug seekers, as well as subsequent prescription drug overdoses.
There are many stray dogs and cats in this county, with only one animal shelter in use. The county dog catcher stays busy. Many people will take unwanted animals to dirt roads and leave them to fend for themselves, which leads to more unwanted animals being born as well as presenting the danger of starving and feral animals coming into people’s yards in search of food.
Out and about in Floyd County, you don’t see many unexpected people. Most people are very similar, being a mix white and working class or poverty level citizens. There are 4 pain clinics in Floyd County, and they stay full and busy. Drug addiction in Eastern Kentucky is probably our most fast growing health related problem, with many arrests for selling and stealing taking place daily. Overdoses of prescription narcotics is a weekly if not daily occurrence at our hospitals.
Political signs are as plenty as mile markers in this county. After voting has ended, it is unusual for the candidates to go round up their campaign signs, which leads to worn and tattered signs staying up for years to come. Cell phone service is limited due to the high mountains but is getting better thanks to more cell towers being erected. Internet access is slow compared to larger cities but most residents do have access.
I would say this county is struggling with poverty and unemployment, but I do think its on its way up. Pike County is our direct neighbor and a 40 minute drive from most towns in Floyd. There have been many new businesses and restaurants added in Pike County recently, which is providing employment opportunities for Floyd County citizenss as well.

Population Health Scavenger Hunt
1.Floyd County Health Department: The target population for this facility is the poor and elderly. Advertisements are commonly found on their Facebook page, and in the local newspaper. The only barrier to services is the location, which is in Prestonsburg, 30 minutes away from a large part of the county. The health department building itself is very modern and nice, it was constructed 5 years ago to replace the old building that was very small, old and in disrepair. This new brick building is 3 stories high, has an elevator and many different departments and offices inside. The employees are dressed mostly in nursing scrubs and have a professional appearance and attitude. They seem to enjoy their job. Various pamphlets on STD’s, Diabetes and maternal health are available as you walk in the door. There is a program available that provides birth control to underage teen girls on a income based sliding scale even without parental permission or knowledge in order to prevent teenage pregnancies. All services provided by the health department are income based, such as: WIC program, Elderly Care, Diabetes Program, Breast Cancer Prevention and Healthy Living Initiative..
2.WIC: The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is a federal assistance program of the Food and Nutrition Service of the United States Department of Agriculture for healthcare and nutrition of low-income pregnant women, breastfeeding women, and infants and children under the age of five. The eligibility requirement is a family income below 185% of the U.S. Poverty Income Guidelines. Located inside the Floyd County Health Department, the WIC program employees are the same nurses and clerks that provide services for the rest of the health department.
3.Mental health: Mountain Comprehensive Care Center is located in Prestonsburg, Floyd County Kentucky and provides mental health services to many of the counties residents. Mental illnesses such as schizophrenia, bipolar disorder, drug and alcohol addiction and mental retardation are some of the disorders treated within this facility. The building itself is a two story brick building located in the center of town. The employees are dressed in casual street clothing and are hurried and very busy with such a large patient load. The lobby is full of a wide variety of people, those who have a caregiver with them due to their developmental disability to those that appear completely mentally healthy, dressed nicely and practice good hygiene. Also many children who have been diagnosed with ADHD sit with their parents while waiting to see the child psychologist. A broad age range is evident within the patients of Mountain Comprehensive Care Center. The target population is the citizens of Floyd County who suffer from any number of mental illness or disability, and offer income based scales for payment of services. This facility uses referrals from doctors. Mountain Comp has a website and a Facebook page.
4.Fire Department: There are three fire departments in Floyd County, the one I chose to visit was Left Beaver Fire and Rescue. This is a smaller than normal metal building located in McDowell, about 1 mile from the hospital where I work. There are 2 fire engines in the building. Three firefighters are on duty, currently cleaning the trucks. Chief Shannon Hall is out for the day, conducting a road block in McDowell to raise money for the department. The workers are friendly and helpful. The target population is anyone in need of their services in the county in which they serve. They have a Facebook page and often post pictures of the firefighters out in the community doing public services.
5.Senior Center: McDowell Senior Citizens Center is an asset to the elderly population of this community. Open Monday through Friday, 6am until 6pm, the senior citizens center offers socialization, meals and healthy living support for anyone age 60 or older who would like to benefit from it. It is a newer building, established in 2005, and was built to meet a growing need of the elderly in our area. The director, Joetta Case, states that the Senior Center has become a staple in the everyday lives of the aging population in Floyd County. The staff of this facility is limited, because many of the members actually help with the cleaning, cooking and planning. The senior center uses Facebook to advertise their many activities and fundraisers to the community such as “The 2015 Senior Games Competition” and bake sales.
6.Food Pantry: God’s Pantry Food Bank is located in Prestonsburg, Floyd County Kentucky. Established in 1955, this food bank has been another asset to Floyd County, where many citizens fall below the poverty line or are unable to qualify for food stamps. This facility has provided healthy and nutrient rich meals, fruit and vegetables to anyone in need for over 50 years. Donations from all over the country keep this pantry open. They have a Facebook page and a website with any information needed. The target population is anyone in need of food. The employees are everyday citizens who mostly volunteer their time and energy to providing food for hungry citizens of Floyd and surrounding counties. I could not find any barriers to this service, as they will bring the food to anyone who is unable to get to their facility themselves due to lack of transportation.

Interpretation Per 1,000 female Floyd County citizens, there are approximately 64.6 births per year. Per 100,000 people in this state, there are approximately 1,135.7 deaths annually in Floyd County. The last available cause of death report took place in 2005, and listed 124 deaths from heart disease, 112 from cancer, and 23 drug related deaths occurring in Floyd County in one year alone. The drug epidemic has only worsened since then, so the data for following years would be much higher. After interpreting the data collected for this report, I feel that poor lifestyle choices are the major cause of health problems and illness related deaths for the citizens of Floyd County.

3 Health Concerns
Tobacco Use: One goal of Healthy People 2020 is to reduce illness, disability, and death related to tobacco use and secondhand smoke exposure. This would greatly help the citizens of Floyd County due to the high rate of tobacco smokers among its population (26%- not counting underage smokers who were not included in the survey). COPD and asthmatic illnesses are prevalent, along with heart disease and diabetes- all illnesses either caused by or exacerbated by smoking.

Nutrition and Weight Status: Another goal of Healthy People 2020 is to promote health and reduce chronic disease risk through the consumption of healthful diets and achievement and maintenance of healthy body weights. In Floyd County, a startling 59% of adults are considered overweight (Kentucky Health Facts, 2015). This means having a BMI of 25 or more. Lack of nutritional education is a contributor to this problem. Many citizens are under educated on the topic of healthy eating.
Substance Abuse: Another goal of Health People 2020 is to reduce substance abuse to protect the health, safety, and quality of life for all, especially children. in 2011, there were 1084 drug related arrests in Floyd County alone. Overdose deaths in Floyd County in 2013: 43.9 per 100,000 Kentucky citizens (Kentucky Health Facts, 2015). in many Eastern Kentucky counties, when compared by 100,000 population. This is due in part to untreated mental illness, which leads people to self medicate and subsequently end up addicted.

Primary Prevention Topic Selected: Overweight and Obesity- Prevention of overweight and obesity through healthy nutrition and physical activity. Poor nutrition and overweight status is a problem that seriously plagues Floyd County. 37% of adults report a lack of physical activity overall in their day to day lives. 59% are considered to be overweight, and 30% have a BMI of 30 or higher, which puts them in the category of obese. Only 19% of Floyd County adults report consuming the recommended daily servings of fruit and vegetables. 14% are asthmatics, 10% are known diabetics, and 34.7% have been diagnosed with hypertension. All these illnesses are related in great part to being overweight and leading a sedentary lifestyle. 3.8% of adults reported that they have not had their cholesterol levels checked in the past 5 years, which leads one to believe that the majority of these people are aware of their poor health choices, yet are unable to change their lifestyles for whatever reason. The Healthy People 2020 website states “Individuals who are at a healthy weight are less likely to develop chronic disease risk factors, such as high blood pressure and dyslipidemia, develop chronic diseases, such as type 2 diabetes, heart disease, osteoarthritis, and some cancers, experience complications during pregnancy and die at an earlier age.”
The programs available to aid in weight loss and healthy weight maintenance are not as common as in some larger cities. Floyd County currently does not have a YMCA, and there is only 1 public gym available, which is located in Prestonsburg and is a 30 minute drive for most citizens, Fresh fruits and vegetables are a treat instead of part of a daily diet, due to the higher expense. The Floyd County Health Department offers prevention teaching to all elementary students once or twice per school year, but this doesn’t help the adult population who are already overweight. The Michelle Obama Nutrition Program has been a help in the school systems, because for most children healthier lunch options were not available until this was put into place. Physical activity needs to be more encouraged in this county. One way to do this is to implement sidewalks and bike lanes so that it is safer to walk to the store, work, etc, instead of driving a car. Another way to implement primary prevention of poor nutritional health is to build a YMCA like facility in which citizens can come and swim, walk, play sports and join exercise groups no matter what the outside weather may be. If these measures were implemented I feel that we would see a dramatic decrease in the percentage of overweight and unhealthy citizens of Floyd County Kentucky.

References
American FactFinder - Community Facts. (n.d.). Retrieved March 02, 2015, from http://factfinder.census.gov/faces/nav/jsf/pages/community_facts.xhtml
Coal Ash Is More Radioactive than Nuclear Waste. (n.d.). Retrieved March 12, 2015, from http://www.scientificamerican.com/article/coal-ash-is-more-radioactive-than-nuclear-waste/
KentuckyHealthFacts.org. (n.d.). Retrieved March 11, 2015, from http://www.kentuckyhealthfacts.org/data/location/show.aspx?cat=1,2,3,5,8,11&loc=36
Motorists advised to watch for deer on the move - Floyd County Times. (2013, October 25). Retrieved March 13, 2015, from http://www.floydcountytimes.com/article/20131025/news/310259952