Running head: PHYSICAL INACTIVITY 1

Physical Inactivity in Hamilton County

Olivia M. Taylor

University of South Florida

Physical Inactivity in Hamilton County

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For healthcare to be effective, it must be delivered via a manner that takes into

consideration the targeted populations strengths as well as weaknesses, resources as well as

needs, and systems, both official and unofficial, that possess significant influence. This paper

looks at Hamilton County, Florida with the goal of proposing effective community level

interventions and health policy that are rooted in an individualized assessment of the community.

More specifically, this paper is focused on the prevalence of physical inactivity within Hamilton

County, the negative effects of such phenomena, and potential practical solutions.

Overview of Hamilton County

Hamilton County, situated in North Central Florida, shares its northern border with the

state of Georgia. Covering 519 square miles, the county is home to 14,665 people (Office of

Economic and Demographic Research [EDR], 2015). The centrally located city of Jasper serves

as the County Seat.

Hamilton County is classified as rural, with 63.5% of the county meeting the criteria of

having a population density that is less than one hundred people per square mile (County Health

Rankings [CHR], 2017). According to the Office of EDR (2015), government jobs make up the

largest percentage of Hamilton Countys workforce, employing 36.2% of working individuals,

while the combined areas of trade, transportation, and utilities claim second place in Hamilton

Countys economy, accounting for 15.9% of jobs. Additionally, the Office of EDRs research

found that jobs in natural resources and mining, particularly the mining of phosphate, are held by

10.5% of the working population.

Hamilton County has an Emergency Medical Services Department, a Public Health

Department, a Rural Health Clinic, and a limited amount of primary care providers that serve its

population and their health needs (Florida Department of Health, n.d.). The Public Health
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Department, specifically, provides pediatric health screenings, immunizations, a prescription

assistance program, and services for women, infants, and children, such as Healthy Start

(WellFlorida Council, 2015). Currently, Hamilton County does not have a hospital operating

within its limits, as the building housing Hamilton County Memorial Hospital, originally opened

in 1952, was sold in 1998. However, the funds from the sale were invested and, overseen by a

Board of Trustees, are being used to assist in funding the Rural Clinic and the Public Health

Department, as the community relies greatly on their services (Hamilton County Memorial

Hospital Board of Trustees, 2017). Although the norms of healthcare vary, to some degree,

among different populations, these deficits in Hamilton County more likely stem from its

relatively low socioeconomic status than from community preference.

Comparison of Local vs. State Populations

When attempting to understand the current socioeconomic state of a community, the first

statistics to consider are those that clearly state how much of the population is living in poverty.

In Hamilton County, 44.5% of children under the age of eighteen live in families in poverty

(CHR, 2017). This number, which has increased dramatically over the past fifteen years, is

essentially double Floridas statewide average of 23% (CHR, 2017). Additionally, while 86.9%

of all Floridians over the age of twenty-five have a high school diploma, only 73.7% of Hamilton

County residents over the age of twenty-five have completed high school (Office of EDR, 2015).

However, potentially due to a lower representation of Hispanic and Asian individuals in

Hamilton Countys demographics than in those of Florida as a whole, only 2% of Hamilton

County residents over the age of 5 report an inability to proficiently speak English; Floridas

statewide average is three times this value, at 6% (CHR, 2017).

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Besides the socioeconomic status of individuals, the availability of primary care

providers and access to health care play a significant role in a communitys overall health.

According to County Health Ratings (2017), for every one primary care physician in the county,

there are 4,680 individuals, while the average for the state of Florida is one primary care

physician for every 1,380 individuals. When looking at other primary care providers, such as

nurse practitioners (NPs) and physician assistants (PAs), the ratio is 14,295 residents for each

provider; this ratio is more than eleven times higher than Floridas overall ratio of 1,272:1 (CHR,

2017). Furthermore, as health is not solely physical, mental health providers are an important

component of a community assessment. The ratio of individuals to mental health providers in

Hamilton County is 14,300:1, a ratio nineteen times higher than the Florida average (CHR,

2017). These values clearly demonstrate an alarming shortage of health care providers in

Hamilton County.

Analysis and Interpretation of Data

Every community has a unique set of strengths and weaknesses; for every area that is in

need of improvement, there is likely another area that is functioning well and efficiently serving

its population. The strengths of Hamilton County appear to be related to the environment and to

large community health initiatives. On the other hand, health indicators that are closely linked to

individualized education and advisement from healthcare providers stand out as weaknesses.

Identified Strengths

According to County Health Rankings (2017), Hamilton County is ranked 10th among the

67 counties in Florida for a healthy physical environment. This is partially due to the absence of

all potential drinking water violations as well as the fact that only 10% of houses in Hamilton

County are classified as having severe housing problems, such as overcrowding and/or a lack of
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kitchen or plumbing facilities; this number is less than half of Floridas statewide average of

22% (CHR, 2017). Childhood vaccination programs in Hamilton County are successful, as

98.2% of Kindergarten children are fully immunized; this is a higher percentage than the Florida

average of 93.4% (Florida Health Charts [FHC], 2015). Despite its shortage of primary care

providers, Hamilton Countys performance in regards to health screening has been trending

upwards, as evidenced by a mammography screening rate of 70%; this value surpasses the

Florida average of 68% and is approaching the national benchmark value of 71% (CHR, 2017).

Identified Weaknesses

Hamilton County performs poorly in the focus areas of exercise and physical activity, as

32% of adults report that they, over the past month, have not performed any physical activity of

their own volition (CHR, 2017). Additionally, only 63% of the population reports accessibility

of exercise opportunities (CHR, 2017). These values reflect significantly lower levels of

physical activity than the state as a whole, as Floridas averages for physical inactivity and

access to exercise are 23% and 92%, respectively (CHR, 2017).

Hamilton Countys sexual activity statistics reveal an area for improvement, as evidenced

by a teen birth rate (69 per 1,000 teenage girls) that is more than double that of the state (31 per

1,000 teenage girls) (CHR, 2017). Similarly, Hamilton County is lacking in maternal and infant

health and education. Only 60.5% of pregnant women receive early prenatal care and 60.2% of

women initiate breastfeeding at birth (FHC, 2015). Both of these values fall well below the

statewide averages for early prenatal care and immediate breastfeeding of 79.5% and 84%,

respectively (FHC, 2015). While each of these weaknesses provide an opportunity for

improvement, the remainder of this paper will be focused on physical inactivity.

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Identification of a Priority Health Issue

Physical activity has, time and time again, been shown to significantly impact an

individuals health in a positive manner. Likewise, research points to physical inactivity as a

serious risk factor for the development of type II diabetes, hypertension, coronary artery disease,

osteoporosis, depression, and cancer of the colon and breast (Sallis, 2015). In fact, it is estimated

that physical inactivity is to blame for 9% of premature mortalities worldwide (Lee et al., 2012).

Lee et al. (2012) go on to say that if physical inactivity were to be reduced by even 25%, over

1.3 million deaths could be avoided each year. For these reasons, increasing the proportion of

adults who meet guidelines for aerobic exercise and muscle strengthening activity is listed as a

Leading Health Indicator of Healthy People 2020 (U.S. Department of Health and Human

Services [HHS], 2014).

In Hamilton County, specifically, the top two causes of death are cancer and heart disease

(WellFlorida Council, 2016). Diabetes is also among the leading causes of death, identified as

number seven on the list (WellFlorida Council, 2016). As these three diseases are associated

with physical inactivity, increased participation in physical activities among community

members has the potential to make a significant positive effect on the health of the population as

a whole.

Discussion and Application of Community Health Models

The priority placed on acute care in the American healthcare system lends itself to

provider-patient interactions that occur in isolation from the patients normal, day to day lives.

When treating acute illnesses and exacerbations, the focus is more on immediate relief and

improvement of symptoms than on targeting underlying causes and preventing recurrence.

However, according to the Institute for Healthcare Improvement (2017), clinical care only
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accounts for 20% of a communitys health. It is factors at the macrosocioecological level, such

as social class, education, and the physical environment, that are responsible for half of a

populations health (IHI, 2017).

In response to this information, Healthy People 2020 has prioritized the implementation

of the Determinants of Health Model when considering the health status of both individuals and

communities. This model recognizes that social factors, government policy, and accessibility of

healthcare, as well as individual behaviors and predispositions, are imperative to community

health (HHS, 2014). The model, therefore, suggests that if a public health intervention is to be

effective, these factors must be considered from its inception.

Regarding physical inactivity, specifically, a communitys environment and access to

safe, clean, and affordable spaces is paramount. In Hamilton County, only 63% of individuals

report access to exercise opportunities (CHR, 2017). A study by Bauman et al. (2012) found that

the environmental factors of walkability, the presence of pavement and safety crossings in the

community, accessibility of recreational facilities, and overall pleasing aesthetics correlate with

higher levels of leisure time physical activity.

When examining the social determinants of physical inactivity, Bauman et al. (2012)

found that an individuals sense of self-efficacy is strongly associated with increased levels of

physical activity. Additionally, the study indicates that the presence of social support is

associated with an increased likelihood of engaging in exercise. This social support is effective

in many forms, be it friends, family members, or an exercise group (Bauman et al., 2012).
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Population Diagnosis

Adults in Hamilton County are at risk for inadequate levels of physical activity related to

limited accessibility to exercise opportunities and insufficient education regarding potential

consequences as evidenced by 32% of adults self-reporting a sedentary lifestyle (CHR, 2017).

Community/Population-based Interventions

While advances in medicine have increased healthcare providers ability to treat disease,

the primary goal should remain prevention. The literature points to physical activity as an

intervention that successfully lowers the risk of multiple chronic diseases with very few potential

negative effects (Booth & Hawley, 2015). It is, therefore, the responsibility of every member of

the healthcare team to promote an active lifestyle among their patients.

Primary Level of Prevention

Research shows that promotion of physical activity within primary care can have a

lasting positive effect on the activity levels of sedentary adults (Williams, Nathan, & Wolfended,

2014). Education regarding the risk reduction for many chronic diseases afforded by regular

exercise should be delivered to patients at the individual level. Recommendations for how often

a patient should exercise and a discussion of possible avenues for achieving adequate activity

should also be included. Currently, the American Heart Association recommends that adults

perform a minimum of 150 minutes per week of moderate exercise or 75 minutes per week of

vigorous exercise (American Heart Association [AHA], 2016). It is important that patients

understand physical activity comes in many forms, such as walking, running, bicycling, dancing,

gardening, golfing, playing with pets, or simply choosing to take the stairs at work, and does not

necessitate an expensive gym membership or exercise equipment (AHA, 2016).

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The individual-level intervention of increased education regarding physical inactivity

would be implemented by healthcare providers on a day to day basis; therefore, they are the key

stakeholders in this situation. Potential resistance to this increased teaching may arise from the

fact that there is not currently a specific billing code for physical inactivity counseling to provide

reimbursement (Joy, n.d.). However, when examined in context of the growing financial burden

placed upon the healthcare system by physical inactivity and its consequences, education is

found to be incredibly cost-effective (Weiler, Murray, & Joy, 2013). As health teaching and

counseling are both components of the Intervention Wheel Model, community health nurses,

specifically, hold a central role in carrying out this intervention (Savage, Kub, & Groves, 2015).

Secondary Level of Prevention

As statistics show a large percentage of adults in Hamilton County are physically

inactive, it is important that healthcare providers are able to identify the individuals who are,

therefore, at a higher risk for a multitude of chronic diseases related to their insufficient activity

level (CHR, 2017). The system-wide implementation of an exercise vital sign (EVS) could be a

quick, yet efficient, way to gain insight into each patients exercise habits (Sallis, 2015). The

EVS, comprised of two questions, asks patients how many days per week, on average, they

perform moderate exercise and the duration, in minutes, of the activity (Sallis, 2015). If

configured within the EMR, the program is able to multiply the two numbers together, allowing

the members of the healthcare team to easily screen for patients who are not meeting physical

activity recommendations (Sallis, 2015).

Healthcare providers are the key stakeholders in this situation, as they would be primary

administrators of the EVS. The success of this intervention depends upon healthcare providers

willingness to utilize the EVS and to consider its results when interacting with patients. In
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regards to cost, the implementation of the EVS does not require significant additional funding or

resources; the two simple questions can be asked in a matter of seconds (Sallis, 2015). The EVS

lends itself to community health nursing, as screening is a component of the Intervention Wheel

Model (Savage, Kub, & Groves, 2015). It does not necessarily require any additional equipment

or technology, allowing it to be easily utilized during community outreach events.

Tertiary Level of Prevention

After inactive individuals are identified and have received education regarding exercise

recommendations, the focus shifts towards implementation and, more importantly, maintenance

of increased physical activity levels. A study completed by Schock, Neher, & Safranek (2017),

discovered that the utilization of a pedometer, along with patient access to the data, resulted in an

increased number of steps comparable to walking an additional mile each day. The data

provided by pedometers provides a way for both patients and providers to objectively monitor

compliance to the physical activity guidelines. On an individual level, healthcare providers

could set specific and personalized daily step goals with their patients while using the data from

pedometers to monitor compliance. At the community level, community health nurses could

initiate a local campaign aimed at encouraging individuals to create their own step goals and

self-monitor progress.

As technology advances, utilization of a pedometer has become more flexible. Many

individuals possess wearable fitness bands or smart phones that are capable of tracking steps. If

a patient has access to these technologies, monitoring adherence requires no additional cost to

the provider. However, many patients do not have access to such technology; in this case, a

traditional pedometer can be used just as effectively. Although inexpensive, pedometers still

have an associated cost. Therefore, in regards to this intervention, public officials are the key
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stakeholders; their allocation of funds could support a community-wide step campaign by

offsetting the cost of pedometers.

Development of Health Policy

Health policies are instituted by either the local, state, or federal government with the

intention of influencing the overall health status of the departments constituents (Savage, Kub,

& Groves, 2015). Health policies have the potential to permanently change not only the

practices of healthcare providers, but also the publics opinions and beliefs surrounding various

health issues. The implementation or modification of health policies highlight priorities, increase

awareness, provide education, and define goals that a community can work together to achieve

(World Health Organization, 2017).

Increasing the education regarding physical inactivity adult patients in Hamilton County

receive from their sources of primary care will be the focus of this health policy. These sources

include physicians, NPs, PAs, and community health nurses working within the Public Health

Department. The institution of this primary level of prevention is aimed at decreasing the

proportion of adults in Hamilton County who are physically inactive.

The National Committee for Quality Assurance (NCQA) rates the quality of care

delivered by healthcare systems using a Healthcare Effectiveness Data and Information Set

(HEDIS); these values are utilized by the federal government as a way to objectively measure

health care quality (NCQA, 2017). Currently, HEDIS measures include an evaluation and

discussion of physical activity levels with patients over the age of 65, as well as with patients

between the ages of 2 and 17 (NCQA, 2017). There is, therefore, an age gap that excludes adult

patients between the ages of 18 and 64 from physical activity discussion with their providers.
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The inclusion of adults in HEDIS measures regarding physical activity would motivate

healthcare providers to discuss exercise habits with each and every one of their patients.

The support and cooperation of multiple stakeholders is necessary to the expansion of

HEDIS measures regarding physical activity. Among them are the Board of Directors of the

NCQA, as their role in initiating and overseeing HEDIS measures positions them as key

stakeholders for this policy. Including adults between the ages of 18 and 64 in their physical

activity measures would support the organizations overall goal of improving healthcare (NCQA,

2017). Additionally, legislators at both the state and federal levels that develop budgets and

funding sources for insurance programs such as Medicare and Medicaid need to be considered as

stakeholders. Considering the growing economic burden resulting from physical inactivity, these

legislators would likely be supportive of promoting the cost-effective intervention of providing

education regarding regular exercise (Booth & Hawley, 2015). Additionally, health care

providers are the ones who actually carry out patient education and the corresponding

documentation in their day to day practice, making their support vital to the success of this

intervention. Potential barriers to their support include a lack of time during patient visits and

the absence of a specific ICD9 code for physical inactivity counseling reimbursement (Joy, n.d.).

The proposition of public health policy should originate from within the community.

With this intervention, specifically, it should begin with a discussion among healthcare providers

and agencies; their opinions and responses should be integrated into the proposal before it is

taken any further. Florida is among the states that mandate the collection of HEDIS measures

and utilize the data for Medicaid purposes (NCQA, 2017). The Public Policy Department of the

NCQA is available as a point of contact for these states and would be a valuable resource for the

initiation of this intervention.

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As this increased education is channeled through preexisting points of contact within

patients communities, it has the potential to benefit underserved populations who are generally

unable to access educational resources offered in distant locations or online. Additionally, as

HEDIS standards are closely tied to Medicare and Medicaid, the educational services will not be

limited to those who are able to purchase private insurance or pay out of pocket. This is an

important aspect to consider in Hamilton County, where 31.8% of all residents are living below

the poverty line (Office of EDR, 2015).

Conclusion

The residents of Hamilton County, due to their sedentary lifestyles, are at an increased

risk for the development of multiple chronic diseases associated with inadequate physical

activity. The expansion of current HEDIS measures regarding physical activity would result in

patients receiving more evidence-based education and counseling concerning exercise. By

imparting knowledge in an understandable and applicable manner, healthcare providers can

equip patients to integrate physical activity into their lives, resulting in a healthier community.

Within my own nursing practice, I hope to not only care for patients, but to empower

patients to care for themselves. In life, there are so many factors we have no control over; no

one is able to choose their genetic predispositions, the community or culture they are born into,

or the opportunities presented to them in the early stages of life. However, each person can, in

their own way, learn to be a good steward of what they have. Education is the foundation of

healthy decision making, such as choosing to care for our bodies through exercise. As a future

nurse, I am excited to take on the role of educator, counselor, and advocate.

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Booth, F. W., & Hawley, J. A. (2015). The erosion of physical activity in Western societies: An

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