The Description of the Community
Geographically, Erie County is located in West New York State, which is surrounded by Lake Erie. The county is also bounded by Canada to the western side, Wyoming and Genesee County the eastern part, Chautauqua and Cattaraugus Counties to the southern side, and the County of Niagara to the north(County of Erie, 2017). The largest city in this county is Buffalo City. Erie is the biggest metropolitan county in the New York’s upstate, whose population was 922,578 according to the census report of 2015 (County of Erie, 2017). The county covers an area of 1,044 square miles (2703.948 square Kilometers). The population in the Buffalo City, which is the seat of Erie County, is 258,071. The demographic data indicates that the 5.4 percent of the population of the county,based on the US Census 2010-2015 data set, comprised the people below five years of age. Additionally, those who were below 18 years accounting for 20.6 percentand 16.8 percent for those who were aged 65 years and above. Reportedly, the County has youths who account for a slightly lower percentage and those aged above 65 years constituting a higher percentage, in comparison with the national and New York State age distribution(County of Erie, 2017). During the same US Census, the data reveals that the age distribution in Buffalo comprised 23.6 percent for the people below 18 years and 11.4 percent for those who were over 65 years of age. It is worthy to note that the percentage for the under 18 people was almost similar to those of the U.S.A (24.0 percent) and that of New York State (22.3 percent). On the other hand, the percentage the people aged above 65 years was lower as compared to the overall percentages of both the New York State (13.5 percent) and Erie County (15.7 percent)(County of Erie, 2017).
In a broader perspective of the County’s demographics, the Buffalo City has more significant diverse racial compositions as opposed to the entire County. The greatest concern, here, is that the white races are the biggest beneficiaries of the healthcare while the blacks and other minority groups are discriminated in the accessibility of such services. For instance, the largest ethnic group in the city that has been disadvantaged is the African-Americans who account for 38.6 percent and 10.5 percent of this Hispanics which are higher as compared to the whole county(County of Erie, 2017). Also, the western part of Buffalo City has over 70 dialects and languages spoken and as well 33 ethnicities.Concerning gender, the population data of the County indicates that the percentage of females is higher (51.6 percent) than that of males (48.4 percent)(County of Erie, 2017). In both Buffalo City and New York State, the situation is still the same where the females are 52.1 percent and males 47.9 percent in the City and 51.4 percent females and 48.6 percent males in New York State (County of Erie, 2017).
In a deeper examination of the physical and social environment of the County, higher levels of poverty have been reported among the non-whites and thus posing a tremendous to threat to the community health sector of the state. This health concern has been associated with the level of poverty may have resulted from the high rates of unemployment experienced in the five zip codes in the city of Buffalo such as 14215, 14212, 14211, 14206, and 14204(County of Erie, 2017). The per capita income and median income from the three of the five zip codes is a half of the income levels of the County and cannot support the people to access the health care within the. Also, the costs of housing in this County have been one of the lowest in the northeastern part of the state, raising health concerns that the department of health needs to address when making a disaster preparedness plan.
The Background Information
Healthy People 2020 forum offers a comprehensive set of national objectives and goals that whose focus is linked to the health concerns of the improving the health of all Americans, including the residents of Erie County. This platform has smaller set of objectives known as Leading Health Indicators (LHIs), whose selection has been for the communication of the high-priority health concerns as well as actions that need to be solved (Healthy People 2020, n.d). In Erie County, non-whites such as Hispanics experience poor mental health in spite of the County having one of the best ratios of resident to the mental health within the AHN nations. Also, the County faces some behavioral health disparities which do not meet the requirements of Healthy People 2020. One of the health concerns to be addressed is the higher percentage of the non-whites, including Hispanics living with a depressive disorder that leads to high risks of getting cardiovascular diseases.
The health concern of cardiovascular disease has been on the rise in Erie since it has been reported to be the leading cause of death among the people of New York and Erie County. The data obtained in 2010 reveals that heart diseases are a higher rate (5.3 percent) in Erie County as compared to the ones in the State of New York (4.4 percent) and the whole nation (4.1 percent) (Catholic Health, 2013). Such rates have been presented in Figure 1 shown below. The heart diseases the residents of the County include heart attack, heart valve problems, angina, and arrhythmia. With this data, the health problem of cardiovascular disease is related to the Healthy People 2020 goals since the frameworks designed aim at reducing the high death rates caused by these diseases. In essence, the Healthy People 2020 provides the strategic opportunities for the promotion of health as well as the improvement of quality of life for all residents of US. Based on this information, the other greatest concern of health involves the determination of cause of health and disease which has been noted as the accumulation of the impacts of the determinants and risk factors for a longer time (Health People 2020, n.d.). Therefore, such a comparison between the health inequality and disparity play a critical role of depicting the importance of intervening at particular points in the course of life for the reduction of the health risk factors and boost health as well.
Figure: Cardiovascular or Heart diseases, self-reported rate per 100,000
The Target Population
The health concerns that have been examined have affected that target population on the basis of gender, age, and demographics such as the level of education and socioeconomic status. In the investigation of the education as a health determinant, the rates of the high school graduation are low, and this condition caused the youth to engage in criminal activities in Buffalo City (County of Erie, 2017). In this city, the rate of high school graduates between 2011 and 2015 was reported to be higher (82.7 percent) as compared to the bachelor’s degree of higher level (24.6 percent). Thus, the preparedness plan targets the people who have attained less than a high school certificates because of their limited knowledge on the health matters in the County. In comparison with this rate, the Erie County’s rate of high school education was higher (90.4 percent), similar to that of that of the New York State (85.6 percent). Also, the rates of the above the degree holders were in the New York State (34.2 percent) and Erie County (31.6 percent) were higher than that of Buffalo City. This data is summarized in Table 3 below.
Table 3: Educational levels attained in Buffalo, Erie County, and entire New York State for the residents aged 25 years and above
Source: County of Erie, 2017, p. 12
Concerning the gender, the data reveals that more males in the County die (6,283) as opposed to the low number of females (4,541) in a period between 2012 and 2014. The plan also targets the relationship between the socioeconomic indicators and the health outcomes of the males who since their big number indicates more health care requirements as compared to those of women. The health concern outcomes also target the low-income, racial, and urban minorities which have been prevalent in the existing literature on this subject. The differences in the median household income in Erie County emanate from the low socioeconomic status which has been noted to be apparent with no consideration of the inadequate housing, the comorbidities of the minority ethnicity, and lack of education. Therefore, the program targets the low-income earners from the minority ethnic groups and the less educated.
Undeniably, the County’s target has been to counter the issue of Pay Equity among males and female, which has been a critical issue in the County and also the State at large. The strategy has targeted women who are vulnerable in this community. This situation is evidenced by the data that has revealed the disparity between the earnings for females and males for the same work they do. For instance, the median earnings of females for employed full time are $37, 639 as compared to that of males which is 50,062 (Bukowski & Quirk, 2015).
Figure 1: The trends of the rates of unemployment between 2004 and 2015 in the County of Erie (Source: County of Erie, 2017, p. 11)
Another target of the program is the unemployment group in Erie County.The rates of unemployment have also led to health disparity conclusion in the County and also the State at large. While the unemployment rate in Erie County in 2015 was 5.4 percent, the rate of the New York State was 5.3 percent. Buffalo City recorded a higher rate (7.1 percent) at the same time (Bukowski & Quirk, 2015). Thus, the trends of the rates of unemployment from 2004 to 2015 have been presented in Figure 1 above. The curves in reveal that there are trends of higher rates of unemployment in January and July in the period of ten years and thus constituting a critical indicator of health disparity that needs to be mitigated. In a historical perspective, this County has been known for having a blue collar community, where the steel industry has been a primary source of employment a large population of Erie County. Nonetheless, the different nature of the County’s population as well as many variables that affect service delivery has emerged a more complex issue than what a quick evaluation of the health disparity would depict.
The Primary Community Resources and Partners
The fieldwork interviews were used to support the health concerns identified in this study. To have a better understanding of the health disparities revolving around the residents of the County of Erie and well get the views concerning the healthcare systems of this County, well-designed questionnaires were prepared and administered to the County members. During the survey, the respondents were expected to complete these questionnaires, where focus groups were also used to source the information regarding the health concerns in the City of Buffalo and the entire County (GRUM, 2014). The residential location of every participant in the meetings of the public was determined from the meeting sign-in sheets. Such interviews and sheets were supportive to the primary health concerns since it involved the allocation of clinical hours in the Community Health based on the population focus objectives and nursing interventions. To this end, every topic selection activity was assigned some hours, and the timeline for the surveys amounting to 90 hours as shown in the Appendix, based on WGU Community Health Clinical Time Log for Students in Unregulated States. The project is expected to be completed by September 30, 2017.
On the other hand, the government document of Erie County Department of Health has been vital resource in providing the data concerning the causes of death in the county. In this county, cardiovascular disease is the leader in the causes of death. This health concern has been evidenced by higher rates of death caused by stroke in the county which are higher than the national rate and about 60 percent greater that the aggregate rate of the New York State (County of Erie, 2017).Furthermore, the residents of Erie County face deaths caused by heart disease accounting for 33 percent above the average citizen of the U.S. Additionally, the economic and social disparities have immensely contributed to the process of cardiovascular disease in the region leading to high number of deaths.Also, the effect cardiovascular disease has been greatly felt by the blacks as compared to another ethnic group in the County. Based on the data provided from 2012 to 2014 for the County’s congestive heart failure hospitalization rate for every 10,000 by ethnicity, the percentages for the black, Asian/Pacific Islander, white, and Hispanic were 47, 25, 19, and 9 respectively. This information is depicted in Figure 1 shown below.
Figure 1: Congestive heart failure hospitalization rate per 10,000 residents of Erie County by ethnicity between 2012 and 2014 (County of Erie, 2017, p.24)
This health situation in the County has called for the collaboration of some partners such as the Affordable Care Act (ACA), Greater Buffalo Urban Ministries (GRUM) and Greater Buffalo United Affordable Healthcare Network (GBUAHN). This partnership soughtto provide community health care intervention for the reduction of high rates of death caused by cardiovascular diseases, and particularly among the minority ethnicity that are vulnerable. ACA has created an emergence of GBUAHN and GRUM concern for the better delivery as well as the health care services quality in the communities, and specifically Latino and African-American. GRUM’s target has been the Latinos and the blacks aged from eighteen to 64 years whose eligibility for Medicaid is sure as well as those with the one or more chronic diseases and are at-risk of contacting disease. The goal of this body has been enroll such people in the program of Medicaid, boost the health care quality of their system, and to enhance their health care system accessibility. Therefore, GRUM has suggested the health activities and programs for the improvement of the health outcomes among the Latinos and African –Americans.
Also, GBUAHN has been linked to the primary health concerns since it constitutes part of the initiative of New York that aids the facilitation of the services of health care to the patients of Medicaid. On the other hand, the Medical Health Homes have sought to integrate and coordinate all the primary and acute behavioral health such as depressive disorder as well as the long-term services. The partnership among Erie County Department of Health, GRUM and GBUAHN involved a collaboration of churches in Buffalo City. The partnership utilized the fact inequalities in health aspects can tackled through the development of a comprehensive technique to the services of healthcare (GRUM, 2014). Particularly, this approached been established in wellness as well as the prevention, whose formation is by the health model’s social determinants. Such a model of health care needs launching deeper into interactive links with the communities of the blacks and Latinos who are affected by the chronic diseases. Thus, thus, the specific community resources were the data from the GRUM churches as well as the neighborhood residents, focused on addressing the health concerns of high death rates by race and ethnicity (GRUM, 2014). This partnership was based on the link between the health inequalities and health disparities in the County, through the development of a comprehensive method of healthcare service. The connection between the inequalities and disparities is rooted in the wellness and prevention functions, and its information is given by the social indicators of the health model.
The Health Concerns not addressed in the Partnership
In spite of the efforts of the partnership that have been discussed several aspects which have not been captured and yet critical in the disaster healthcare preparedness. Firstly, healthy eating is essential for the preparedness for the health disparities, but this has not been captured in the initiatives of the partners involved in the Community health assessment. Research has indicated that people face this issue because health eating in the City as well as the County has proved to be very expensive since such foods are costly and also cooking them is tricky (Department of Health, n.d). The prior studies reveal that many people in the County have little knowledge concerning nutrition and thus this situation has resulted in health concerns that need to be taken into account while preparing for the disparities in the offing. Some residents in the City and also the County have indicated that their inability to make such meals has made them to crave for the foods which are not healthy such as junk foods.
Another important aspect that the partnership in the Community health disaster preparedness has not given weight is the physical exercise, particularly for the overweight and obese people. The findings of the surveys that have been conducted previously depict that the health disparities in the County have emanated from lack of enough physical exercise (Department of Health, n.d). For instance, people have found it difficult to exercise on regular basis and thus implicating the outcomes of the health concerns. One of the reasons that the residents of Buffalo have for this problem is that most people lack time to do it, or feel tired, and others have a notion that the neighboring environment cannot allow do exercises like walking among other outdoor activities. Another reason for this situation is the City of Buffalo has inadequate facilities for the exercise such as gyms. This problem has been expected in the City because of the long winter, snowy, and cold conditions. It is even worse snowy seasons since the sidewalks that people need to use for the exercise cannot be passable when winter starts, which compels people to walk in the streets. The studies have also revealed that many residents cannot walk and thus making the exercise difficult. Having a closer look at these kinds of health concerns, researchers have arrived at some conclusions that there lacks an active culture that can engage people in exercise for a healthy living.
Food security is another critical aspect that the partnership with GRUM and GBUAHN has not addressed to the fullest. There is a necessity for an understanding that food security is crucial in the development of the people’ lifestyle that is healthy, which gets rid of the inequalities of health and thus leading to the generation of the health outcomes.However, it has to be noted that the concept of food security revolves around the people’s access safe, nutritious, and adequate food for the maintenance of an active and healthy life. It also comprises having the resources and knowledge that one needs to buy nutritious and safe food. In some studies on the health literacy, researchers wanted to get insights concerning the knowledge of nutrition as well s the exercise of the residents of Buffalo and Erie County (Department of Health, n.d). They also examined the socioeconomic factors thwarting the ability of the people to have access to nutritious and safe food. In another broader context of the rate of health literacy, researchers have described it as the level to which people have the capacity to gain, understand, and process the health information and services which are requirements for making proper decisions concerning health.
Other studies sought tom examine the conditions of housing the neighborhood as a vital element in the need to generate the health outcomes that are desirable and the removal of the inequalities of health. This aspect constitutes one of the unmet objectives of GRUM and its partners which have called for further investigation for an in-depth analysis of the health issues affecting Erie County and Buffalo City (GRUM, 2014). Thus, it is crucial to have knowledge of the status of housing and neighborhood so as to enhance the health conditions of the residents of the community and GRUM parishioners. Within this context, there is a need to assess the health of the community based on whether people live in own or rented houses. In this case, the is a critical concern of housing tenure which is significant since the renters have to rely on the owners of the property for the improvement of the quality of the units of housing that belong to them. Also, the how old a house is constitutes another imperative health concern because the older the house gets, the higher the costs of maintenance. It is not surprising the repairs and maintenance costs where older housing units are involved leads to the rise in the economic problems on the owners, which comprise the class of property management and the landlord. Therefore, such issues have depicted housing units having many issues that lead to the existence of further health problems in Erie County.
Additionally, the partnership with GRUM did not place emphasis of the natural disasters such as earthquakes, wave action, and ice jams among others which pose a challenge to the City of Buffalo and Erie County. Most importantly, these aspects have not only caused damage to the properties but also many deaths and thus posing a health challenge (GRUM, 2014). In a wider perspective of disaster preparedness, the community health assessment should identify the locations within the City or the County which are vulnerable so as to effectively reduce the impact of such natural disasters.
The Outcome Identification
The desired goal or outcome for the improvement of the health concern in the County was related to those set for the Healthy People 2020 that entailed focusing on the improvement of the health of all American. For instance, the programs developed in the city such as GRUM initiatives placed their focus on improving the lives of then people aged 18 and years. This age group was selected because these people have eligibility to Medicaid and some are prone to more than one chronic disease, and could be vulnerable to the acquisition of another disease (GRUM, 2014). Based on this aspect, the comparison between the health disparity and inequality has raised concerns among the researchers has considered the presence of is a racial and class dimension that have also resulted in the health concerns in the United States. There has been a notion that the low-income class and the black people have higher chances of experiencing health issues and have limited accessibility to the system of health care as compared to the whites and higher income class. This idea is based on the manner in which the health care system in the U.S. works.
In Buffalo City, the overrepresentation of chronic diseases has depicted mortality, preventable hospitalizations, and morbidity. In a similar vein, there has been the concentration of the city residents who are not insured has resulted in a large population of Medicaid as well as the population that is eligible to Medicaid with more than one chronic disease, with a higher risk of getting another (GRUM, 2014). On the other hand, the group of low-income earners has been found to be overrepresented in Buffalo City. In this case, the health outcome is that there is an intensive concentration of the individuals who are eligible to Medicaid or have enrolled in it.
Also, in Erie County, the health care, comprising the care quality and accessibility, was placed in position eleven in 2014. Since that time, the network of healthcare in Buffalo City has been supported by numerous systems of big hospitals, which encompass the Catholic Health System, Roswell Park Center Institute, the County Department of Health, Kaleida Health, the Veterans Administration (VA) Hospital Care System, and the Erie County Medical Center Corporation (GRUM, 2014). Additionally, the health care system of Buffalo has facilities of long-term care, urgent care facilities, over a thousand affiliated physicians, and many outpatient clinics. Moreover, there have been the health insurance associations, together with many institutes and organizations like the social service providers, the P²Collaborative, and the Wellness Center. In this context, many organizations have played a critical role in the provision of the social and health care services to the membership of Medicaid (GRUM, 2014). Through this framework, health care and education have constituted the greatest economic sector of the region, where their growth has been catalyzed by the Buffalo Niagara Medical Campus (BNMC as well as the University at Buffalo.
The health outcomes for the Latinos and the blacks in the New York State have not been desirable, despite Erie County being the leading health care system. Based on this case, there is a necessity of attaining a deeper understanding of the socioeconomic pressure and the neighborhood that impede health care accessibility and wellness of the people in the City of Buffalo and the County of Erie as a whole. In consequence, this approach seeks to fulfill the goal of improving the health outcomes and as well remove the health discrepancies among the residences, which is similar to the goal of the Healthy People 2020 for the Americans (Healthy People 2020, n.d). This understanding has made it possible for the creation of a system design which would eliminate the hindrances to better health, and thus leading to increased quality of health and wellness among the Latinos and African-Americans. Therefore, this approach has been a cornerstone for the attainment of the improved health outcomes for these two ethnic groups in the County of Erie.
Planning
The creation of a nursing action plan is necessary if the identified health concerns have to be resolved. In the first, place, the clinical team of the City will need to seek collaboration of the community and follow a particular chronological development ideas so as to achieve the goals of the health care system. For instance, the Community Health Assessment scheduled for 2016 to 2018 involved the New York State Department of Health calling for the local health departments to form a partnership with the hospitals (Department of Health, n.d). This has also been the moment when the hospitals should seek for collaboration with the health departments on the Community Service Plans therein.
To attain the goals of the health, Erie County needed to come up with appropriate health improvement plans. The deaths due to chronic disease in Erie County were planned for as shown in Table 4 below. This table indicates the community health improvement plan that Erie County needs to use so at address cases of chronic diseases in the offing. The action takes into account the potential public and private partnership for the implementation of the discussed recommendations. The measurable outcomes that were connected the primary health concern on the basis of the population-focused goals, making it possible to come up with the population-focused nursing interventions are appropriately indicated in the table. The health concerns that the action seeks to address are the reduction of the number of deaths and determine the causes of deaths including the cardiovascular diseases among other chronic disease within the county.
Table 4: The Community Health Improvement Plan to mitigate Chronic Diseases
| Outcome objective | Population Focused Goals | Population Focused Nursing Interventions | Measurable Tools | Partner Resources | The role of Partnership | Time line for interventions |
| To reduce overall number of people dying due to Cardiovascular diseases | To cut down deaths because of Cardiovascular activities in the County | Implementing Hearts project program in the County of Erie. The date of accomplishment will be June 30, 2017. | Implementing of the initiatives to reduce heart diseases and strokes. | Blood pressure machines, time, supplies, and staff to address chronic diseases | Hosting educational programs concerning the reduction of deaths in the County. The community partners such as GRUM and GBUAHN for the integration of in everyday’s events such as hosting of BP screening stations by Pharmacies to diagnose cardiovascular disease. | June 30, 2017 |
| To increase participation the County’s population in the self managementof evidence-based programs | To increase awareness on the importance of self-management programs for cardiovascular diseases among residents of Erie County | Promotion of the enrollment of population in the local programs of Stanford Model Evidence- Based Chronic Disease Management, expected to end on July 31, 2017. | Holding of the programs, the number of lifestyle changes, and the number of attendees. | Supplies, space, and diagnosis equipment. | Community health centers, disease referrals. | July 31, 2017 |
| To increase rates of awareness of cardiovascular diseases and their management in the county | Reduce misconceptions, stereotypes, and ignorance on cardiovascular diseases through mass education | Self-monitoring programs of blood pressure to determine the existence of Heart diseases and stoke, completion date expected to be August 31, 2017. | Campaigns of pharmacy education, site of community screening | Staff time, supply (BP machine), and space. | Provision of education to patients, referrals, and self-monitoring station of host blood pressure, | August 31, 2017 |
| To raise the rates of screening for cardiovascular diseases among the populations that is disparate. | Improve the rates of early detection of cardiovascular diseases to encourage management | Rising of opportunities for the evidence-based screening as well as the referrals in the Federally Qualified Health Centers for Cardiovascular disease, date of completions being September 30 , 2017. | Screening of the number of patients with heart diseases and then referring them to the treatment. | Supplies, staff, blood pressure machines, and time. | Education, FQHC’s, space, and ProvidersProvide referrals | September 30, 2017. |
Evaluation
The establishment of a system of summative and formative evaluations will require the utilization of an external evaluator to assess the effectiveness of the nursing action plan created and as well monitor its progress (Bukowski & Quirk, 2015). Such evaluations are needful as an instrument for strengthening the intervention plan as well as device a strategy of continues development and improvement. Additionally, the process of evaluation needs to monitor the movement of the program recommended to achieve the critical benchmarks and also ensuring the program does not compromise its initial purpose.
In this case, performance indicators of the chronic diseases have been used as a measurable tool of the nursing action plan.A bigger and more complex evaluative system needs to be created for each program of health and community development centers since cardiovascular diseases process are complex. In spite of this approach, one of the critical elements that the evaluative system needs to take into account is the percentage and number of the residents of the community that have been enrolled by the center and can effectively access the heart disease services offered (Bukowski & Quirk, 2015). Furthermore, the action plan will be considered effective based on how well it will address the health disparities identified in Erie County and also mitigating the health risks associated with such discrepancies. Consequently, measurement of the plan’s effectiveness will seek to attain the goals of the disaster preparedness programs for quality life among the residents of the City and the County based on how well the plan address the causes of death.
Moreover, the capabilities and resources are the necessary measurable tools for the performance for the assessment to determine the effectiveness of the nursing action plan. The capability assessment was useful in the investigation of the ability of the participation of the County of Erie in the implementation and management of a comprehensive strategy of mitigation, including a variety of mitigation actions (Bukowski & Quirk, 2015). In the evaluation, there is a necessity of identifying the weaknesses, threats, opportunities, and strengths of the strategies for the development of the health disaster mitigation programs that are effective. Added to this idea is the identification of the capabilities of the collective evaluation of the community health assessment to help in the development of the recommendations toward the reduction of cardiovascular diseases.
Conclusion
In preparation for the health disparities, there have been local, state, and national efforts toward a population that is healthier. Based on the findings in the fieldwork, it was evident that Erie County had several health inequalities and disparities such as chronic diseases which need to be addressed at a county, nation, and state level. The health concerns in the County include the high rates of unemployment that has resulted in the poverty levels and also levels of education. The department of the County’s community health department has found it useful to seek collaboration with the public and private health agencies to mitigate the health disparities for the improved quality life of the residents. The timeline for the implementation of the program is 90 hours running through September 30, 2017.
References
Bukowski, V &Quirk, J. (2015). Erie county community health needs assessment. Erie Community Department of Health.
Catholic Health, (2013). Community Health Needs Assessment and Community Service Plan. Retrieved from <http://www.chsbuffalo.org/files/Documents/Community%20Health%20Needs%20Assessment/FINAL%20-%20CHNA%20CSP%20Assessment.pdf>
County of Erie, (2017). Erie County New York co mmunity health assessment 2017-2019. Erie County Department of Health. Retrieved from http://www2.erie.gov/health/sites/www2.erie.gov.health/files/uploads/pdfs/cha.pdf
Department of Health, (n.d).About prevention of quality indicators. Retrieved from https://apps.health.ny.gov/statistics/prevention/quality_indicators/about/prevention_quality_indicators.jsp
Department of Health, (n.d). Prevention agenda 2013-2018:New York State’s health improvement plan. Retrieved from https://www.health.ny.gov/prevention/prevention_agenda/2013-2017/index.htm
GRUM, (2014).Striving for a Healthier Buffalo, December 2014 Final Report. Retrieved from https://ubwp.buffalo.edu/aps-cus/wp-content/uploads/sites/16/2015/04/Final-GRUM-Community-Health-Needs-Assessment_December-2014-2.pdf
Healthy People 2020. Leading Health Indicators. Retrieved from https://www.healthypeople.gov/2020/Leading-Health-Indicators
