Health Equity Assessment 2021

The Health Collaborative in partnership with the UNC Greensboro's Center for Housing and Community Studies completed a comprehensive health equity evaluation in the Dan River region.

The assessment engaged residents and social service agencies, eliciting health system feedback and promoting community support. It also identified barriers that health impacted communities face in accessing primary health services or addressing Social Determinants of Health (SDOH) such as economic stability, educational and employment opportunities, healthy housing, nutritious foods, active lifestyles, and overall wellbeing.

Read the  executive summary , the  full report , or view  data used  here. An overview presentation may be viewed below.

"This report reminds us that health starts where we live, learn, work, and play and for this reason, we need everyone – not just public health professionals – to be part of the work to support health for all people. For several years, The Health Collaborative’s partnerships have broken down silos and built connections across sectors. We have engaged residents, worked to build and repair trust, and fostered a culture of collaboration and learning across the region. The social capital and community capacity built has allowed us to have hard conversations about the root causes of poor health and health disparities and has highlighted areas of shared concern. With this strong foundation, we can align efforts, leverage resources, and maximize capacity in ways we couldn’t before and in ways no one organization could do on their own. While this progress may be hard to measure, we know that today, we are much more prepared for this long-term effort and much better equipped to address the complex challenges we face. Though there is still much work to do, we hope you feel proud of how far we’ve come and inspired to continue this deep work together."

The Dan River Region (composed of Pittsylvania County and City of Danville, VA & Caswell County, NC) has an estimated population of 125,010 residents which are partially rural (62%), mostly white (63%), and black (32%). About 2.5% of the population is foreign born.

Fifty-nine percent (58.9%) of the population is of working age (18-64) while 21% of the population is 65 or older. The median age of the population in the Dan River Region is approximately 44.6 years, as compared to the national median age of 38.0. The area has been experiencing recent population declines, in part due to the aging community and out-migration after the tobacco industry dissolved.

These maps are interactive! Click on them to view population details.

Greater than one out of every seven adult residents in each area of the Dan River Region is estimated to have poor mental and/or physical health. A third of residents do not engage in enough physical activity and 40% do not get enough sleep. High blood pressure, high cholesterol, and arthritis were among the most prevalent health conditions affecting the region. Though the majority get annual physicals however just under two-thirds receive routine dental care. Only about a third of those ages 65+ are up-to-date on the core set of clinical preventative services.

Health issues mentioned by key informants were often associated with poverty and often referenced in tandem with social determinants of health. COPD, diabetes, high blood pressure, kidney disease, obesity, respiratory problems were specifically cited as issues in the region. The Danville-Pittsylvania area was distinguished as having the highest estimated rates of diabetes in Virginia in 2019 at about one-in-five residents. Across the region it was estimated that as much as 75% of the population is overweight or obese in 2019.

Mental health issues such as isolation, depression, schizophrenia, bipolar, and stressors of poverty were among the most-mentioned chronic health problems. In particular people were concerned about the mental health of the elderly and children.

Almost all tracts within the Dan River Region fell below the estimated life expectancy for VA, NC, and the United States. In Virginia, the rate of death from all causes is 822.9 per 100,000 residents, substantially lower than the rates in Danville (1820.5), as well as Pittsylvania (1257.6) and Caswell (1195) counties.

While heart disease and cancer are not as prevalent as some other health conditions affecting the region, they are consistently highest ranked for lethality, sometimes doubling or even tripling the rate of the third leading cause of death. Unintentional injuries, which include overdoses, are also highly ranked. Police, fire, and EMS in Danville reported that 68% of overdoses between 2019 and 2021 involved opioids. The issue of drugs was raised among community members as well.

The conditions in the Dan River Region have a profound impact on residents health and overall wellbeing. Factors related such as economic stability, housing, transportation, education, and access to healthcare, healthy foods, and parks not only influence quality of life but how long someone may live. Often these issues are linked to location, or where people live and work.

The median income in the Dan River Region ranged from $37,203 to $47,690, about 30-35% lower than state averages. There is also great variability within the region. A few Danville neighborhoods in particular have median household incomes above $80,000 while others are less than $13,500. Median household income was found to be one of the strongest predictors of life expectancy.

Low income and income inequality are the drivers of many health equity issues in the Dan River Region. About thirty percent of households live on less than $25,000 annually. Poverty affects about 18.9% of the population compared to the national rate of 13.4%. Among community survey respondents, 31% reported not having enough money to pay for medical bills as a leading issue affecting health inequities.

Half of disposable income of most households goes to transportation and housing costs. About 18% of homeowners and about two-fifths of renters are cost-burdened, meaning gross rent and utility expenses make up 30% or more of the household income. About 44% of survey respondents said that there are not enough affordable housing options for people making at least minimum wage. Housing conditions are also a health consideration.

Income is linked both to economic opportunity, access to resources, and educational attainment. One-in-five (18.0%) of the population has less than a high school education while about half of the population has had some college education or more. Perceptions of the quality of the local schools are low, with only 33.6% of survey respondents believing the area has good quality public schools.  

For those wanting a college education, there is little in the way of opportunities or incentive to stay in the region. Due to limited local employment opportunities many people commute elsewhere making employment heavily reliant on access to transportation. The region is largely vehicle dependent with limited access to public transportation, sidewalks, greenways, yet 16.3% of Danville households do not have access to a vehicle.

Food insecurity in the region has decreased in recent years with the annual food budget shortage dropping from $10,699,000 to $8,744,000. About 12-15% of the general population, and about 19-25% of children in the region are food insecure.

Though food insecurity may be sporadic, households may consider trade-offs between paying for their basic needs such as housing and healthcare or buying food. Without access to transportation or healthy food sources, populations are at higher risk of obesity and negative diet-related health conditions such as diabetes and cardiovascular disease. 

These maps are interactive! Click on them to view food, housing, and transportation details.

A third of the region's population lives in a food desert. As pointed out by key informant interviews, Dollar General may be the closest option and a trip to a grocery store with fresh produce may take 30 minutes. As one resident said, "One of the things I did notice in this community, that it is a food desert, and that you have grocery stores that are kinda outlying that area, but even the stores that are close to where I’m residing right now, they are a disaster, as far as keeping the community well."

The community has recreational facilities throughout the area, though access is largely dependent on having transportation. It was also noted that rural areas had fewer options and some areas have better amenities than others. "There are a ton of parks around Danville, but the ones that are near the low-income areas have been kind of let go." However, informants did feel that many of the recreational programs were an asset to the community and had positive comments about the improvements to community resources.

Perceptions of community safety varied among Dan River residents. Some reported feeling "very safe" while others said, "people are afraid of crime". These concerns extended past the urban/rural divide, though Danville was specifically called out for issues relating to violent crime, weapons, and gang activity. Danville has generally higher crime rates than Pittsylvania and Caswell Counties, however the areas of Yanceyville and northern Pittsylvania County along the 29 corridor were also found to have higher incidence of violent crime as well. Each jurisdiction implements policies and procedures differently, therefore comparisons should be made cautiously. 

As a result of the above presented information, five key issues pertaining to health inequity were identified. They are #1 racial disparities in health care, #2 poverty as the root cause of disparity, #3 housing quality, affordability, & costs, #4 transportation access, and finally #5 insurance & health system navigators.

While 36.5% of the population is non-white, African Americans are especially geographically concentrated in a few neighborhoods in Danville and Yanceyville. Neighborhoods of color were geospatially correlated with higher rates of poverty, lack of insurance and lower health opportunity indices, greater disease morbidity and mortality, higher risk for COVID-19, etc. This translated clearly into lower Health Equity Scores for these neighborhoods relative to other parts of the region. While some interviewees and focus group participants were hesitant to attribute inequalities to race, there was clear evidence of the experience of inequity in healthcare, and in the society at large, from Black participants. This was also dramatically illustrated in the survey where twice as many Black respondents said they had experienced discriminatory treatment in interactions with health care settings. One resident said, "There is a feeling of inequity when it comes to the quality of care or the services that are provided based on, you know, the race of the individual going for services."

Poverty is the most significant driver of health disparities affecting both urban neighborhoods in Danville as well as rural areas in both counties. Approximately one-in-five of the population was below the poverty line in 2019 (23,647 individuals) and 15% of households have less than $15,000 in income (ACS 2019). Several tracts in Danville and in the Milton/Semora area saw child poverty levels above 50%. Poverty in these areas was correlated with high unemployment, fewer vehicles, lower educational levels, and food deserts. Poverty was also one of the strongest negative correlates of life expectancy. Inability to pay for insurance, co-pays, prescriptions, and other health-related costs was a theme in stakeholder interviews and community focus groups. Interviewees noted that “If people do get sick, or they need even just to go get check-ups or anything like that, they feel like they don’t have the funding nor the health insurance to be able to do so, so they don’t go” and said that economic considerations were the major factor in explaining health inequities. Among our respondents to the community survey, not having enough money to pay for medical bills was the leading issue identified by 31.1% of respondents.

While housing in the Dan River Region is perceived to be more affordable, more than half of renters (42%) were cost burdened paying more than 30% of their income towards rent. The lack of affordable choices in neighborhoods with goods schools, nearby employment, full-service supermarkets, and low crime rates is an underlying issue causing those with low incomes to be further segregated and concentrated in precarious communities with neighborhood resources. Interviewees agreed that the scarcity and bad condition of much housing is a contributor to poor health outcomes. Overcrowding, lack of plumbing (5% of homes), lack of complete kitchen (6.5% of homes), high lead exposure risk, and other severe problems plagued the housing stock. Participants discussed people living in substandard housing, especially in rural areas.

Transportation issues emerged in all contexts. While 16.3% of households in Danville have no vehicle, 9.1% of Caswell households, and 5.7% of Pittsylvania households also are without transportation. There are some census tracts where more than a third of households are without a car. Having a vehicle was a protective factor in our Health Equity Score with a very high statistical correlation to life expectancy. Lack of transportation was an overarching obstacle and social determinant, having a decisive effect on access not only to health care but to social services, education, employment, recreation, food and people’s ability to connect with others in the community.

The updated 2020 health ranking for Danville remained unchanged as one of the least healthy areas in Virginia (lowest 0-25%) in both health factors and health outcomes. Pittsylvania County fell from 75th to 90th out of 133 and Caswell County fell from 54th to 78th out of 100 in North Carolina, becoming more high risk for adverse health factors and outcomes. Insurance is a key factor. Throughout conversations, the blunt truth kept repeating itself, that if you don’t have insurance, you almost literally don’t have access to healthcare. 8.6% of Pittsylvania, 9.0% of Danville, and 7.4% of Caswell residents are completely without insurance. Even then, some with private insurance policies don’t have excellent coverage: “I have insurance, and there are times when I don’t take myself or take my children to the doctor, because of the cost.” Those purchasing coverage through the marketplace may face the reality that not all services are covered, or they have high premiums and deductibles or out-of-pocket costs. More low-to-moderate income people fall into a gap, “People who make too much money to qualify for Medicaid and not enough money to pay for a private insurance.” For those who are eligible, Medicaid is a bridge over many of the obstacles, but there are drawbacks, among them limits to what doctors will accept it and limits to what it will cover.

Based on the information and issues shared above, a Health Equity Score was computed and mapped for the Dan River Region as a summative index of health and wellbeing which can be compared across the region. It considers factors related to socio-demographic, community safety, preventative health care, chronic disease, life expectancy, and wellness indicators.

Below you can compare the Health Equity Score and 2021 report data to the percent of adults in poverty and other data metrics from the 2017 report.

These maps are interactive! Click on them to explore.

Key informants and participants of the Health Collaborative's Summit were asked to share one thing they would do, one new program they would implement, or one policy they would change (if they were in charge and money were no object) to promote healthy equity. Respondents suggested the following:

• Universal health care coverage
• Funding for additional specialists in the Region
• Better transportation choice
• Mobile clinics & outreach in isolated areas
• Address food systems & housing affordability
• Encourage More Civic Caring & Community Resilience

Suggestions were tied together with the recommendation for social cohesion, support, and resiliency among the community rather than material resources. These ideas were used to make the following recommendations for next steps in addressing health equity seen below.