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Home My WebLink About2024 Gallatin County Community Health Assessment Report 1 2024 GALLATIN COUNTY COMMUNITY HEALTH ASSESSMENT REPORT Mission: To promote and protect health in the communities we serve. Vision: Healthy people, healthy environments, thriving communities. TABLE OF CONTENTS Introduction and Letter from the Health Officer .......................................................................................... 5 Acknowledgements ....................................................................................................................................... 6 Executive Summary ....................................................................................................................................... 8 Key Takeaway from Each Model Component ........................................................................................... 8 Health Department Commentary on Importance of These Findings for Gallatin County ...................... 14 Top Strengths ...................................................................................................................................... 14 Top Opportunities ............................................................................................................................... 14 Project Description and Process ................................................................................................................. 15 What is Health ......................................................................................................................................... 15 Purpose of the Community Health Assessment ..................................................................................... 15 Scope of Project .................................................................................................................................. 15 Alignment with Community Health Improvement Plan and Strategic Plan ....................................... 16 Process: Team and Community Role and Engagement .......................................................................... 16 Core Group Description, Role, and Engagement ................................................................................ 16 Community Committee Description, Role, and Engagement ............................................................. 16 Community Partners, Health Department Staff, and Board of Health Description, Role, and Engagement ........................................................................................................................................ 17 Process: Methodology ............................................................................................................................ 17 Description of Jurisdiction and Timeline/Cycle ................................................................................... 17 Health Model Development Process and Metric Selection ................................................................ 18 Relationship of Social Determinants of Health to Community Engagement and Process Design ...... 21 Findings ....................................................................................................................................................... 23 Community Profile .................................................................................................................................. 23 Demographics ..................................................................................................................................... 23 Community Context ............................................................................................................................ 27 Health Outcomes .................................................................................................................................... 40 Introduction ........................................................................................................................................ 40 Morbidity ............................................................................................................................................ 41 Mortality ............................................................................................................................................. 60 Health Factors ......................................................................................................................................... 76 Health Behaviors ................................................................................................................................. 77 3 Access to Services ............................................................................................................................... 93 Social and Economic Factors ............................................................................................................. 105 Cost of Living .................................................................................................................................. 109 Environmental Factors ...................................................................................................................... 110 Conclusions: Top Strengths and Opportunities ........................................................................................ 122 Top Strengths ........................................................................................................................................ 122 Top Strengths from Health Department Perspective ....................................................................... 123 Top Opportunities ................................................................................................................................. 124 Top Opportunities from Health Department Perspective ................................................................ 124 Next Steps ............................................................................................................................................. 126 Community Health Assessment Used to Develop the Community Health Improvement Plan ........ 126 Evolution of Community Health Assessment, including Possible Future Data Collections Based on Findings ............................................................................................................................................. 127 Appendices ................................................................................................................................................ 128 Appendix 1: Leading Causes of Death ................................................................................................... 129 Appendix 2: Known Gaps / Areas for Future Exploration ..................................................................... 132 Community Context .......................................................................................................................... 132 Morbidity .......................................................................................................................................... 132 Mortality ........................................................................................................................................... 132 Health Behaviors ............................................................................................................................... 132 Access to Services ............................................................................................................................. 133 Social and Economic Factors ............................................................................................................. 134 Environmental Factors ...................................................................................................................... 134 Appendix 3: Additional Methods Discussion ........................................................................................ 135 Model Design and Definitions ........................................................................................................... 135 Community Committee Member List ............................................................................................... 143 Community Committee Engagement ............................................................................................... 145 Acknowledging the Use of Chat GPT ................................................................................................. 146 Appendix 4: Focus Group Discussion and Key Informant Interviews ................................................... 147 Recruitment Process ......................................................................................................................... 147 Participant Registration .................................................................................................................... 148 Discussion and Interview Protocols .................................................................................................. 148 4 Appendix 5: Data Biography and Inclusion Criteria .............................................................................. 150 Description of Statistics .................................................................................................................... 152 Data Inclusion Criteria ....................................................................................................................... 152 Appendix 6: Community Asset List ....................................................................................................... 154 Health Outcomes: Length of Life ...................................................................................................... 154 Health Outcomes: Quality of Life ...................................................................................................... 156 Health Factors: Health Behaviors...................................................................................................... 160 Health Factors: Access to Services .................................................................................................... 164 Health Factors: Social and Economic Factors ................................................................................... 167 Health Factors: Environmental Factors ............................................................................................. 168 Appendix 7: List of Acronyms, Figures, and Tables ............................................................................... 170 List of Acronyms ................................................................................................................................ 170 List of Figures .................................................................................................................................... 170 List of Tables ..................................................................................................................................... 176 Appendix 8: Reference List for Figures ................................................................................................. 177 Appendix 9: Reference List For In-Text Sources ................................................................................... 195 5 INTRODUCTION AND LETTER FROM THE HEALTH OFFICER December 18, 2024 I’m pleased to share the 2024 Community Health Assessment (CHA) with you. This report is the result of months of hard work, teamwork, and input from people all around our community. So, what is a Community Health Assessment? It is a process where we gather and analyze data to understand our community's health status, needs, and resources. This process helps us figure out the most important health issues, service gaps, and areas where we can improve. With this information, we collectively develop strategies to tackle the unique health challenges our community faces. This recent Community Health Assessment has given us great insights into the health landscape of our community. We have identified several key areas to focus on, such as mental health, housing affordability and availability, chronic disease prevention, water quality and quantity, as well as access to healthcare services to name a few. Addressing these issues will require the collective efforts of healthcare providers, community organizations, local government, and, most importantly, you, the residents of Gallatin County. I want to extend my heartfelt thanks to everyone who contributed to this assessment. Your input and collaboration have been invaluable. I also want to thank the dedicated team of public health professionals who worked tirelessly to gather and analyze the data, making sure this report is both comprehensive and accurate. As we move forward, I encourage all members of our community to engage with the findings of this assessment. By working together, we can create a healthier, more vibrant community for everyone. I look forward to continuing this important work with you and making meaningful progress in addressing our community’s health needs. Thank you for your commitment to the health and well-being of our community. Sincerely, Lori Christenson, MPH Health Officer, Gallatin City-County Health Department 6 ACKNOWLEDGEMENTS The process of developing a community health assessment is truly collaborative and would not be possible without the time, energy, and contributions from community representatives. The Gallatin City- County Health Department would like to sincerely thank the following people and organizations. Within each category, individuals are listed alphabetically by surname. Individual roles listed where provided. Funding Montana Department of Public Health and Human Services, Foundational Public Health Planning and Implementation Community Committee Lauren Buxbaum, Behavioral Health Care Manager, Bridgercare Lindsay Charlton, Board Member, West Yellowstone Senior Center Cristina Chiotti (preceded by Amber Long), Assistant Director in Student Wellness, Montana State University Erin Clements, Youth and Family Outreach Program Director, Gallatin County Sheriff’s Office Danika Comey (preceded by Christopher Coburn), Chair, Gallatin City-County Board of Health Krista Dicomitis, Strategic Planning Officer, Human Resources Development Council Lisa Forsman, Patient Aligned Care Team Social Worker, Veterans’ Affairs Sophia Fortunato, Engagement and Events Coordinator, Thrive Nicol Fountain, Montana Language Services Ben Frentsos, Greater Gallatin United Way Dani Hess, Community Engagement Coordinator, City of Bozeman Kelly Keenan, Director of Prevention Services, Gallatin City-County Health Department Kami Kirchberg (preceded by Laurie Walker), System Manager of Community Health Improvement and Partnership, Bozeman Health Kiernan McCarthy, Programs Manager, Wellness in Action Kirsten Michels, Registered Dietitian, Bozeman Public Schools Katie Moyer, Gallatin Valley Land Trust Russ Nelson, Mayor, City of Belgrade Katie Neuman, Providence Mental Health Desirea Rees, Family Services Manager (preceded by Carmen Rubio), Family Promise Kareena Robinson, Director of Programs, Haven Tey Silva, Community Health Partners Erin Taylor, Gallatin County Sheriff’s Office Sarah Volesky, Family Engagement Coordinator, Child Care Connections Sheree Watson, Environmental Subcommittee, Gallatin City- County Board of Health 7 Core Group, Gallatin City-County Health Department Staff Kate Batchelder, Accreditation Coordinator Lori Christenson, Health Officer Joanna Fink, Epidemiologist Travis Horton, Director of Environmental Health Services Kelly Keenan, Director of Prevention Services Anna Snyder, Director of Health Provision Service External Review Mark Bond, Regional Housing Coalition Krista Dicomitis, Human Resource Development Council Kirsten Smith, Gallatin Behavioral Health Coalition Data Collaboration Bozeman Health Community Health Needs Assessment Focus Group Discussion Participants Gallatin Behavioral Health Coalition (GBHC) Lewis and Clark Public Health Montana Department of Public Health & Human Services (DPHHS) Montana Office of Public Instruction (OPI) State/Community data sources Editing, Formatting, Communications Support Buck Taylor, Principal, BMT Consulting, LLC Holly Whaley, Communication Specialist, Gallatin City-County Health Department AmeriCorps VISTAs Sophia Fortunato, Raven Yurtal Intern Sarah Compton 8 EXECUTIVE SUMMARY The 2024 Gallatin County Community Health Assessment was a collaborative effort that aimed to understand the health status, needs, and assets of Gallatin County. It analyzed comprehensive data on the community, health outcomes, and health factors to identify strengths and opportunities, aligning with the standards of the Public Health Accreditation Board. The findings will be integral to guiding local public health practice, including community health improvement efforts, by ensuring that community health priorities are grounded in a data-driven understanding of the community's health. The assessment process involved three layers of stakeholders: the Core Group of health department staff, the Community Committee of local organization representatives, and community partners, including other community members and organizations. The Core Group led the project’s design, data collection, and decision-making, while the Community Committee provided diverse perspectives and co- created key elements of the assessment. Community partners offered feedback and expertise helping to validate the findings to ensure they reflected the needs and realities of Gallatin County. The Community Health Assessment provides a comprehensive picture of community health by incorporating diverse perspectives and balancing rigorous methodology with practical constraints like data availability and staff capacity. It used a locally adapted health framework, based on the County Health Rankings model, to guide data collection across three categories: community profile, health outcomes, and health factors.1 The Core Group selected key topics and metrics, while the Community Committee co-created content for the Health Factors category through collaborative sessions. Due to limitations in data availability, the assessment relied predominately on secondary data sources, supplemented by primary qualitative data to address specific gaps. The process emphasized understanding health disparities and ensuring community engagement through regular communication and opportunities for public input. KEY TAKEAWAY FROM EACH MODEL COMPONENT As of 2022, Gallatin County’s estimated population was approximately 124,857 residents, reflecting a significant growth of roughly 35% since 2012 (Figure 19). About 65% of the county was described as “urban,” classified by encompassing at least 2,000 housing units or a population of at least 5,000 (Figure 4). Census data indicated that 52% of Gallatin County residents are male and 48% female (Figure 3). Notably, the local university (Montana State) influences the age distribution, with the most prevalent age group being young adults aged 20 to 24, who accounted for approximately 12% of the population (Figure 3). Following closely were those aged 25 to 29 who comprised 9% of the population, and people aged 30 to 34 years who made up 8% of the population, highlighting a relatively young community overall. Census data from 2022 indicated that about 96% of Gallatin County residents were born in the United States, with 38% hailing from Montana and 62% from other states or territories (Figure 9). Among those born outside of the US, nearly half (51%) are considered naturalized citizens (Figure 9). Additional census data from 2020 indicated that an estimated 5% of Gallatin County's residents are Hispanic or Latino, which is a 2% increase from 2010 (Figure 5). The majority (89%) of the non-Hispanic or Latino population 9 identified as White, marking a decline of about 6.1% from 2010 to 2020 (Figure 6). According to estimates from 2022, 96% of the county’s residents speak English, while 4% are non-English speakers. Among residents who do not speak English as a primary language, Spanish was the most common language, spoken by 59% of non-English speakers, followed by Asian and Pacific Island languages at around 25% (Figure 6). As of 2022, an estimated 53% of adult residents in the county held a bachelor's degree or higher, surpassing the 34% observed in both Montana and the United States (Figure 10). This strong educational foundation is paired with a relatively low high school dropout rate; from 2014 to 2023, only an average of 1.7% of students in Gallatin County did not complete high school, compared to Montana's rate of approximately 2.4% (Figure 11). A 2003 study highlighted a concerning trend in health literacy across the nation, revealing that only about 12% of U.S. adults possess proficient health literacy skills. This underscores the importance of ongoing efforts to improve health education and accessibility, especially in rapidly growing communities like Gallatin County.2 Local data on literacy was limited, however, model-based estimates combined with results from a 2017 study reported that a higher percentage of adults in Gallatin County are highly proficient in literacy and numeracy compared to the state of Montana.3 Gallatin County is predicted to experience substantial growth, with population projections suggesting a 34% increase by 2040, bringing the total to roughly 167,528 residents (Figure 21). The median annual household income increased by about 58% during the last decade, from $52,833 in 2013 to $83,434 in 2022 (Figure 15). Subgroup-level data highlights that the Hispanic or Latino population in the county face higher poverty rates, recorded at 20%, compared to 24% in Montana and 17% nationwide (Figure 16). Gallatin County hosts a robust job market, with an estimated unemployment rate of about 2.1% in 2023, lower than the rates for both Montana and the United States, which stand at 3.0% and 3.6%, respectively (Figure 13). Workforce participation rates throughout the county varied between sexes, with males averaging 87%, females averaging 79%, and females with children under age 18 averaging 73% participation in the labor force between 2015 and 2022. Both of the leading industries within the county are closely tied to the tourism sector. As of 2023, the top two industries in the county were Retail Trade and Accommodation and Food Services, making up about 13% and 15% of jobs, respectively (Figure 12). Housing trends also reflect Gallatin County’s economic growth, as the area had a high percentage of owner-occupied homes valued at $300,000 or more, estimated at 83%. Within Montana and the United States, the percentage of homes valued at $300,000 or more was much lower, with about 51% and 47%, respectively (Figure 17). The number of licensed tourist homes surged dramatically, from just 39 in 2017 to 349 in 2024, although not all homes licensed in a given year continue to operate. As of August 2024, there were 855 active tourist home licenses in the county (Figure 18). Behavioral risk factor data from 2020-2021 indicated that among adults in Gallatin, Madison, and Park Counties, 8% reported being physically unhealthy for at least half of the prior month (Figure 22). 10 Additional behavioral risk factor data indicated a 4% decrease in the percent of adults self-reporting poor or fair health status in Gallatin, Madison, and Park Counties between the 2016-2017 and 2020- 2021 estimates (Figure 23). Obesity rates within the county have risen from 16% to 24% during the past decade, also reflecting statewide and national trends (Figure 28). Diabetes prevalence remained low and relatively stable in the county compared to state and national estimates; approximately 5% of Gallatin County adults reported having diabetes in 2021 compared to about 8% of adults in Montana and the United States (Figure 29). Mental health concerns have emerged as a growing issue throughout the nation in the past several years.4 Data from the Bozeman Help Center revealed that mental health-related calls accounted for 44% of all inquiries in 2022, consistent with 2020 figures but reflecting an increase of 15% since 2018 and 31% since 2016 (Figure 38). Additionally, an estimated 13% of adults in Gallatin, Madison, and Park counties reported feeling mentally unhealthy for at least half of the past month in 2021-2022, which represented a 6% rise from 2016-2017 estimates (Figure 39). Approximately 9.2% of Gallatin County residents live with a disability, with variations observed across different sexes, races, and age groups (Figure 24). Notably, American Indian residents were disproportionately impacted by disability, with an estimated 29% of the population reporting being disabled compared to 9% of the White population in 2022 (Figure 24). Older individuals also were disproportionately impacted by disability, with about 44% of residents aged 75+ years experiencing disability compared to 8.4% of those aged 35-64 years (Figure 24). Cancer incidence also varied between several subgroups; an estimated 504 males per 100,000 had cancer compared to 401 females per 100,000 (Figure 27). Cancer incidence also was much higher in older age groups within the county, with approximately 2,069 cancer cases per 100,000 residents aged 65+ compared to 214 cases of cancer per 100,000 residents aged 64 years or less (Figure 27). Overall, the incidence of cancer in Gallatin County was slightly higher than the national average, particularly for prostate and breast cancer (Figure 27). Since the onset of the COVID-19 pandemic in March 2020 through July 31, 2024, Gallatin County had reported 45,144 COVID-19 cases and 1,488 hospitalizations related to the virus (Table 2). Influenza data highlighted a surge in cases during the 2023-2024 season, with approximately 1,917 cases per 100,000 residents compared to 843 per 100,000 throughout the 2013-2014 season (Figure 33). Among sexually transmitted infections, chlamydia was the most common disease throughout Gallatin County, with 1,172 cases reported in 2022-2023, marking an increase of 145 cases compared to 2018-2019 (Figure 36). Among births in Gallatin County, the prevalence of preterm births was recorded at approximately 8.6% between 2014 and 2018, which was only slightly lower than the statewide estimate of 9.0% (Figure 42). Similarly, the prevalence of low birth weight among newborns in the county stood at 7.6%, compared to 7.5% statewide (Figure 42). Additionally, the percentage of pregnant women receiving prenatal care in the first trimester in the county was about 76.7% compared to 71.7% throughout Montana (Figure 42). Heart disease remained the leading cause of mortality across Gallatin County, Montana, and the United States. In Gallatin County, it accounted for an estimated 138 deaths per 100,000 residents, slightly lower than the national rate of 167 deaths per 100,000 and the statewide rate of 166 deaths per 100,000 11 (Figure 44). Following heart disease, cancer represented the second-highest cause of death, with an age- adjusted mortality rate of approximately 117 deaths per 100,000 residents in the county, compared to 142 deaths per 100,000 in Montana and 146 deaths per 100,000 in the United States (Figure 44). Unintentional injuries among county residents were responsible for the highest level of years of potential life lost, causing an estimated 4,800 years of potential life lost between 2018 and 2022 (Figure 44). The most prevalent cause of unintentional injury deaths in the county weas accidental falls, which accounted for about 11 deaths per 100,000 residents (Figure 53). This rate is comparable to national estimates and lower than the statewide rate of 15 deaths per 100,000 (Figure 53). Additionally, motor vehicle accidents accounted for approximately 10 deaths per 100,000 residents, also slightly lower than both the state and national averages of 19 and 12, respectively (Figure 57). Infant mortality within Gallatin County was estimated at approximately 3.3 infant deaths per 1,000 live births between 2013 and 2022 (Figure 47). The county infant mortality rate was lower than Montana’s rate of 5.3 per 1,000 and the national average of 5.6 per 1,000 live births (Figure 47). Increasing suicide rates in Gallatin County showed a disturbing trend. In 2022, the suicide rate was estimated at 25 deaths per 100,000 residents, marking a 9% increase from 2016, when the rate stood at 23 deaths per 100,000 (Figure 50). Both Gallatin County and the state of Montana exhibited higher suicide rates compared to the national average, indicating a need for enhanced mental health resources and interventions (Figure 50). Lastly, life expectancy data from 2010 to 2015 revealed an average of 80.9 years among 19 of Gallatin County’s census tracts that had sufficient sample sizes. This figure offers a glimpse into the overall health and longevity of residents, though it also underscores the disparities that may exist. Data related to understanding health behaviors in Gallatin County present a complex picture. Although specific data on how the community comprehends these behaviors is lacking, insights from 2024 local focus groups revealed a strong awareness among residents regarding the differences between healthy and unhealthy choices. Participants noted that, despite this awareness, many community members struggle to prioritize health due to the high cost of living and other financial pressures. This often forces them to focus on affordable basic health needs, sidelining other important aspects of well-being. Community interaction data from 2018-2022 indicated that only 4% of adults aged 65 and older in Gallatin County live alone, which is lower than both the state and national averages (Figure 61). Interaction data among Gallatin County’s youth population highlighted that 23% of high school students and 35% of middle school students reported experiencing bullying on school property within the last year (Figure 62). Additional student-level data from Gallatin County schools indicated that 67-68% of surveyed middle and high school students reported spending three or more hours per day on screen time (not including for schoolwork) in2023, representing a 9-11% increase from 2021 (Figure 63). Substance use is another area of concern throughout the nation.5 Data from the Montana Board of Crime Control highlighted that between 2014 and 2023, the number of drug seizures (excluding marijuana) rose by 89% in Gallatin County (Figure 68). Among the illegal seizures, most (58%) were associated with methamphetamine or other stimulants, which is similar to the proportion of seizures occurring throughout the state as well (Figure 69). Data among county youth indicated that in 2023, 51% 12 of high school students and 28% of middle school students reported having consumed more than a few sips of alcohol (Figure 66). Additionally, 35% of high school students used electronic vapor products, a decline from 43% in 2017. Among adults in Gallatin, Madison, and Park Counties, 10% reported smoking tobacco in 2020-2021, while 7% used smokeless tobacco products (Figure 70). Additionally, during the same survey period, 22% of adults reported binge drinking, marking a 50% increase from 2018-2019 (Figure 71). Between 2017 and 2023, most middle and high school students indicated that they consumed fruits at least once a week, although fewer students reported eating vegetables regularly (Figures 72 and 73). In 2022, around 12% of Gallatin County residents experienced occasional food insecurity, a rate comparable to those in Montana and the United States (Figure 74). Physical activity data highlighted that 14% of the adult population in Gallatin, Madison, and Park Counties reported not engaging in any exercise within the past 30 days in 2020-2021 (Figure 79). Notably, this inactivity is more pronounced among specific age groups, particularly individuals aged 18 to 24 and those over 65. According to 2020-2021 data from the Behavioral Risk Factor Surveillance System, 18% of adults in Gallatin, Madison, and Park counties reported not having had a medical provider’s appointment in two or more years (Figure 81). A 2023 Community Health Needs Assessment conducted by Bozeman Health shed light on the potential reasons behind this lack of healthcare access or utilization; among the 264 respondents who reported delaying or forgoing healthcare services, nearly half (49.6%) cited cost as the primary barrier, while 33% indicated that their insurance did not cover the necessary services (Figure 85). The cost of healthcare services also presented barriers to residents. Additional behavioral risk factor survey data from 2020-2021 reported that 10% of adults in Gallatin, Madison, and Park Counties were unable to see a medical provider due to financial constraints, though this figure represents a slight improvement, down 2% from 2018-2019 (Figure 91). Mental health services also present access challenges for residents of Gallatin County. From 2016 to 2023, the county consistently reported a lower ratio of residents to mental healthcare providers compared to both state and national averages (Figure 88). In Bozeman Health’s 2023 Community Health Needs Assessment, 18% of the 463 respondents reported not accessing mental health services due to cost, while 7% mentioned not knowing where to go for help (Figure 89). Following the Medicaid “unwinding” process, enrollment numbers for both adults and children in Gallatin County saw a slight decline (Figure 92). Peak Medicaid enrollment occurred in April 2023, with 3,538 individuals enrolled, while the lowest enrollment point was in December 2023, dropping to 2,405 (Figure 92). Additionally, the percentage of the population receiving cash assistance or SNAP benefits has steadily decreased, falling from above 6% in 2013 to around 4% in 2022 (Figure 94). Housing affordability remains a prominent issue for Gallatin County residents. As of 2022, 37% of housing occupants in the county were renters, while 63% owned their homes (Figure 96). This contrasts with trends seen across Montana and the United States, where a higher percentage of residents are homeowners (Figure 96). The median home sale price in Gallatin County was recorded at a staggering $662,000 in 2023, well above the national median of $514,000 (Figure 97). This disparity highlights the escalating housing costs in the region and underscores the challenges faced by renters and potential 13 homebuyers. Housing affordability challenges also are apparent through census data indicating that approximately 47% of renters in Gallatin County reported spending more than 30% of their income toward rental costs as of 2022 (Figure 98). Community discussions have further illuminated the concerns surrounding the cost of living in Gallatin County. Local focus groups held in 2024 revealed that residents were increasingly worried about their ability to afford basic necessities like groceries or medications. The qualitative data gathered during these discussions emphasized that many individuals and families were grappling with the financial pressures that come with living in an area where housing prices are on the rise. The high cost of living within the county also was apparent through childcare cost data as of 2023; the cost of childcare in Gallatin County was over 35% higher than throughout Montana and about 29% higher than throughout the rest of the United States (Figure 95). Housing availability in Gallatin County has become a pressing issue, particularly in the wake of the COVID-19 pandemic. In 2019, there were an estimated 116 homeless residents, but that number surged dramatically to 409 by 2024, marking a staggering 252% increase over five years (Figure 103). During the pandemic, 2020 data collection efforts were hindered due to concerns about virus transmission complicating the understanding of the full impact on the homeless population. Among the county’s students, an average of 215 (1.6%) have experienced homelessness from 2012 to 2023, which is slightly lower than the statewide average of 2.6% (Figure 104). Community focus groups were conducted in 2024 to delve into how housing availability affects health in the region. Participants expressed significant concerns about the limited options for affordable housing, with many unable to qualify for subsidized programs. This situation often forced residents into substandard living conditions, sharing housing with others, or even relocating out of the area. One participant poignantly captured the sentiment, stating: “It’s a very unsettling power dynamic that exists between tenants and landlords because housing isn't available and isn't affordable, and there's definitely a lot of people that are being taken advantage of.” Additional barriers, such as pet fees, further restricted access to suitable housing. Census data related to housing quality indicated that as of 2022, 24% of owner-occupied homes in Gallatin County were built before 1979, which was notably lower than the state and national averages of 46% and 48%, respectively (Figure 102). Beyond housing, environmental factors such as air quality and water resources were evaluated in relation to the community’s health. From 2000 to 2023, Gallatin County experienced a notable variation in air quality, with the number of days classified as having moderate to hazardous air quality ranging from 24 to more than 160 (Figure 106). The highest frequency of poor air quality days occurred between 2008 and 2011 (Figure 106). Water quality is also a concern, as shifts in precipitation patterns have led to more rain and earlier snowmelt, affecting groundwater levels and stream flows. This shift can result in the concentration of pollutants, including nitrates. The increasing temperatures in the region further exacerbate water evaporation, while rapid population growth places additional strain on municipal water supplies, leaving no legally available water for expansion. 14 Transportation data showed that the percentage of students not always wearing seatbelts increased from 38% to 53% among middle school students and from 38% to 42% among high school students between 2017 and 2023 (Figure 99). Seatbelt data among adults in Gallatin, Madison, and Park Counties indicated that about 25% of adults reported not always wearing a seatbelt in 2020-2021, up 4% from 2018-2019 estimates (Figure 100). Additionally, as of 2022, about 73% of residents commuted to work alone in their vehicles, with only 9% carpooling, which can contribute to traffic congestion and emissions (Figure 101). HEALTH DEPARTMENT COMMENTARY ON IMPORTANCE OF THESE FINDINGS FOR GALLATIN COUNTY The findings from the Community Health Assessment are crucial for Gallatin County as this information provides a clear understanding of both the strengths and opportunities within the community. Recognizing the county's strong economic indicators, low disease rates, and effective public health initiatives can help build on existing successes to further enhance community well-being. Meanwhile, identifying key opportunities can enable targeted interventions that can reduce health inequities and improve overall community resilience. The top strengths and top opportunities summarized below are informed by the comprehensive data summaries provided throughout the report. TOP STRENGTHS This Community Health Assessment highlights a range of strengths that contribute to the overall well- being and resilience of the community. Gallatin County has a thriving economy with high income levels, high education rates, low unemployment, and community growth. The community has achieved reductions in tobacco use, particularly among youth, while maintaining low diabetes prevalence and lower mortality rates compared to state and national averages. Enhanced access to healthcare services, high youth condom usage, stable medical care during COVID-19, and low vaccine-preventable disease incidence further highlight the community's robust health profile and commitment to public health. These strengths create a strong foundation for continued health improvements and strategic interventions aimed at addressing identified health needs in Gallatin County. TOP OPPORTUNITIES The Community Health Assessment identifies several opportunities for improvement in Gallatin County’s well-being and resilience. While Gallatin County is collectively a healthy and prosperous community, there are social and economic disparities that impact the population including high living costs, housing affordability issues, and barriers to healthcare access. The county faces higher suicide rates compared to national averages, increasing drug overdose deaths, and high alcohol misuse among adults and youth. Many community members, including most youth, lack sufficient physical activity, and cancer rates for prostate, breast, and melanoma are above state and national averages. Many young people face challenges related to mental health and report experiencing bullying. There was insufficient information to assess how well individuals interpret and make meaning from health information. Addressing these issues is crucial for enhancing community health in Gallatin County. 15 PROJECT DESCRIPTION AND PROCESS The Community Health Assessment project is a collaborative effort led by the Gallatin City-County Health Department. The project involved the work of health department staff and a Community Committee during the course of several months with the intent of better understanding the multi- faceted picture of health in Gallatin County. WHAT IS HEALTH Health is a complex production of many interconnected factors. To establish a common understanding and fundamental framework, the Core Group and Community Committee adopted the World Health Organization definition of health which states, “health is a dynamic state of complete physical, mental, spiritual, and social well-being and not merely the absence of disease or infirmity.”6 The Public Health Accreditation Board also uses this definition to underpin its work and to establish a common framing of health. As a health department accredited by the Public Health Accreditation Board, the Gallatin City- County Health Department applied this definition throughout the community health assessment project. PURPOSE OF THE COMMUNITY HEALTH ASSESSMENT The Public Health Accreditation Board has an established set of standards and measures that guide the work of accredited health departments. The first of these standards is to assess and monitor population health status, factors that influence health, and community needs and assets. Specifically, according to the standard, the Community Health Assessment, “paints a comprehensive picture of a community’s health status, factors contributing to higher health risks or poorer health outcomes, and community resources available to improve health.”7 To ensure alignment with the accreditation standards, Gallatin City-County Health Department used this definition as the foundation of this assessment cycle. SCOPE OF PROJECT The Public Health Accreditation Board standards state that a community health assessment should consider all members of the community for which the health department has jurisdiction, that is Gallatin County, Montana. As such, the assessment considered Gallatin County and all individuals living in Gallatin County to be the scope of the assessment. PUBLIC HEALTH ACCREDITATION BOARD REQUIREMENTS The Public Health Accreditation Board requires accredited health departments to conduct a community health assessment at least every five years. The Public Health Accreditation Board states that the assessment must include data from multiple sources (primary, secondary, quantitative, and qualitative) that describe the community’s demographics, health status, morbidity and mortality, socioeconomic characteristics, quality of life, community resources, behavioral factors, the environment (including the built environment), and other social and structural determinants of health status. Further, the Public Health Accreditation Board requires accredited health departments to identify disparities and factors that contribute to disparities. The health department also must involve a variety of partners from the community throughout the entire process. The design and implementation plan of this project considers and incorporates all of these requirements, and they are described in the content of this report. 16 GALLATIN CITY-COUNTY HEALTH DEPARTMENT COMMITMENT Beyond the requirements of the Public Health Accreditation Board, the Gallatin City-County Health Department is dedicated to using data to inform its practices. The health department also has a strong commitment to conducting community health assessments over the span of many years and has actively used those data to inform improvement efforts internally as well as collaboratively with partners across Gallatin County. The health department commits to regular data collection efforts to understand the comprehensive and dynamic picture of health for residents in Gallatin County. ALIGNMENT WITH COMMUNITY HEALTH IMPROVEMENT PLAN AND STRATEGIC PLAN As part of its organizational development, the Gallatin City-County Health Department includes data from the community health assessment in its strategic planning process. The data from the assessment help guide the future direction of the department to evolve its work in ways that continue to meet the organizational mission: To promote and protect health in the communities we serve. PROCESS: TEAM AND COMMUNITY ROLE AND ENGAGEMENT The Community Health Assessment is a collaborative effort that engages internal health department staff and external partners. Throughout the project, three layers of stakeholders have been involved: first, the Core Group of health department staff are responsible for the design, implementation, and decision-making of the project; second, the Community Committee of representatives from organizations across Gallatin County are engaged at key stages to co-create and influence the direction of the assessment design and data interpretation; and third, the Community Partners are all other individuals or organizations in Gallatin County and surrounding areas who might be interested in the project or the outcome of the project as it relates to them personally or professionally. CORE GROUP DESCRIPTION, ROLE, AND ENGAGEMENT The Core Group is comprised of the Accreditation and Health Equity Coordinator, the AmeriCorps VISTA, the Division Directors (Environmental Health, Prevention Services, and Provision Services), the Epidemiologist, and the Health Officer. This group of health department staff make up the team of public health professionals who designed and developed the content of the project, engaged the Community Committee in co-creation activities, communicated updates to Community Partners, collected and summarized data, and wrote the findings reports. Ultimately, this group makes final decisions and takes action related to the assessment project. The Core Group will continue its involvement and leadership into the community health improvement plan process. COMMUNITY COMMITTEE DESCRIPTION, ROLE, AND ENGAGEMENT The Community Committee is a group of approximately two dozen representatives from organizations active across the domains of the social determinants of health in Gallatin County (see Appendix 3). The Community Committee is charged with providing oversight and a diversity of professional perspectives throughout the process. The Community Committee ensured that diverse sectors, subpopulations, and perspectives contributed to the creation of the assessment throughout the entire process. The Community Committee was engaged at multiple key points for co-creation and input (see Appendix 3 for 17 more details on Community Committee Engagement). These key points included co-creating the health model, ranking the health model topics for selection, recruiting for focus group discussions, validating the preliminary data (and suggesting or providing additional data sources), identifying or confirming community assets, ranking prioritization criteria, and prioritizing the opportunities from the assessment to form the basis of the community health improvement plan. The Community Committee will continue its work in the Community Health Improvement Plan phase; however, the exact composition of the committee might change to reflect the goals and activities outlined in the plan. COMMUNITY PARTNERS, HEALTH DEPARTMENT STAFF, AND BOARD OF HEALTH DESCRIPTION, ROLE, AND ENGAGEMENT The role of the Community Partners is to provide broad community ground-truthing and feedback to the Community Health Assessment. Community partners also were contacted as subject matter experts to provide feedback on specific areas of the assessment relevant to their work and expertise. The health department has kept community partners updated on progress through bi-monthly email newsletters. At the outset of the project, the Core Group created a webpage on the health department’s HealthyGallatin.org website. The page is dedicated to keeping the community partners updated about the Community Health Assessment project by posting project updates such as current and past newsletter content. The Community Partners represent critical community organizations, the local public health system, and partners who advocate on behalf of community members impacted by public health issues. These partners may also have access to data related to populations experiencing unmet needs. An example of this collaboration can be seen in the data sharing between the health department and the Gallatin Behavioral Health Coalition, specifically the Bozeman Help Center call data. These data describe the most common types of help center calls (mental health), enhancing the understanding of how individuals in Gallatin County are seeking services related to mental health. This layer of the project also includes all health department staff and Board of Health members as well as any and all interested community members. PROCESS: METHODOLOGY The goal of the community health assessment is to provide a comprehensive overview of health for individuals in Gallatin County. To achieve this, the assessment covers various health-related topics and data and includes diverse community perspectives to ensure accuracy and relevance. At the same time, it was necessary to balance a rigorous and rich approach with the real practical limitations such as data availability and staff capacity. The content that follows describes the methods that were used to accomplish this balance. DESCRIPTION OF JURISDICTION AND TIMELINE/CYCLE Gallatin County, Montana is the jurisdiction of the Gallatin City-County Health Department and is the “community” assessed in this project. The Public Health Accreditation Board Reaccreditation Standards, Version 2022, requires that accredited health departments conduct a community health assessment at least every five years. Variation in the frequency and the methods of previous community health assessments pose challenges for data comparability. Despite the differences in frequency and approach, 18 the assessment remains a valuable tool for the health department and its partners to understand general health trends and identify opportunities for improvement. HEALTH MODEL DEVELOPMENT PROCESS AND METRIC SELECTION A health model is a representation of how a system of influences produces the health of the community. The details of the health model guide the data collection process. The specific model depiction is tailored to the community context and therefore the details of the health model vary from place to place. As such, the process of creating the health model is informed by both public health professional expertise and local community knowledge and expertise. In this project, the health department acts as a convener to solicit voices from professionals and community organization representatives to identify the evidence-based and locally informed details of the health model for Gallatin County. The process for creating the health model started in August 2023 and continued to the end of December 2023. Various agencies in the public health field have created health models, so as a first step in creating the health model for this assessment cycle, the Core Group reviewed multiple existing health models. Ultimately, the group selected the County Health Rankings health model as its basis which was then adapted to fit the local Gallatin County context.8 Before turning to the process of adapting the model to the local context, it is useful to describe the overall structure of the model. As stated previously, the assessment considers a spectrum of influences and system-level factors that produce and impact the health of the community. This spectrum of influences is organized into the three categories of the model, namely: community profile, health outcomes, and health factors. Each of the categories is composed of multiple themes and within each theme there are multiple topics. Figure 1 below shows the three categories with the themes and topics within each. 19 Figure 1: Gallatin County Community Health Assessment Health Model Finally, metrics are the pieces of data that illustrate the topics. The information in the table below provides an example from the Health Outcomes category of the model. Table 1: Health Model Component Example Category Theme Topic Metric Health Outcomes Length of Life Suicide Age-adjusted rate per 100,000 over time The process of determining the exact topics to be included in the model happened in two phases. In the first phase, the Core Group determined that the topics within the Community Profile and Health Outcomes categories of the model were considered public health fundamentals, and as such, the Core Group would be responsible for selecting topics and metrics that were appropriate from the public health perspective. The second phase related to identifying topics for the Health Factors category of the model. The Core Group determined that the Community Committee and the members’ diversity of perspectives was best suited to work on the development and local adaptation of the Health Factors category of the model. To 20 do this, the Community Committee convened for a working session in October 2023. The session was designed so that the Community Committee would collaborate and co-create the content and topics within each of the four Health Factors themes. In order to do this, the Core Group developed a set of questions and definitions that served as a framework for the conversation at the working session. Following a session of guided brainstorming, the Community Committee generated a rich list of possible topics, specifically adapted to the local Gallatin County context. However, more topics were identified during this working session than would be possible to include due to staff capacity limitations. As a next step in the following weeks, the Committee was asked to rank the list of initial topics using another set of simple guiding questions that established common framing for the ranking process. The top-ranking topics were selected to be included in the health model for this assessment cycle. The final list of health model categories, themes, topics, and definitions of those topics is available in Appendix 3. ATTENTION TO AREAS OF INEQUITY/DISPARITY The use of data and decisions based on data can have powerful consequences, whether intentional or not. Therefore, doing what is possible to paint a truly and accurately comprehensive picture of health in a community is critical for a community health assessment. To extend this thinking, it is important to understand where there are differences in health within a community, and to investigate whether these differences might be linked to characteristics of the community itself. Throughout the data collection and summary process, the Core Group did what was possible to use datasets that could be disaggregated by different characteristics such as by urban/rural, age, race, or other attributes. Due to the nature of using secondary data sources, this was not always possible and is a limitation to the overall picture of understanding health for all residents of Gallatin County. It is important to note that data sources and data decisions are the product of many iterative decisions and the consequences of those decisions. For example, the census datasets are reliable for gathering data about communities. However, some of the residents of a community may not be counted due to sensitivities such as immigration status or unstable housing. A decision was made to collect data in a certain way, and that data collection might not truly reflect the full picture of who lives in a community. The Data Biography (available in Appendix 5) outlines some of the key characteristics of the datasets used in this assessment. DATA SOURCES AND INCLUSION CRITERIA Nearly all of the data used in this assessment were sourced from secondary quantitative datasets. Using secondary data was necessary to fit the project within the constraints of staff capacity and budget. To describe the health model topics and metrics, existing secondary data sources were researched and vetted using established inclusion criteria (see Appendix 5). Data were obtained from national, state, and local sources. Data were summarized and presented in charts and graphs. Due to the heavy reliance on secondary sources, data were not always available to describe the precise topics or metrics desired by the Core Group and Community Committee. 21 Primary data were collected to fill specific gaps and to add nuanced understanding to two specific health model topics, namely the impacts that cost of living and housing availability have on health for Gallatin County residents. Data collection protocols were developed specifically for this primary qualitative data collection activity. More information about the recruitment strategies and discussion protocols can be found in Appendix 4 of this report. Appendix 8 lists the references for all data presented in the figures throughout the report. Appendix 9 lists the references for all other in-text citations. NOTE TO READER ON DATA CHARACTERISTICS Due to the diverse characteristics of the many datasets used in this assessment, it is important to note that each dataset had its own characteristics and parameters. Simply put, it is important for the reader to review the figure title, axis labels, and units of measurement for each figure in the report to ensure accurate interpretation of the information presented. Some figures might present summaries of annual data whereas others present combined years, for example. A full data biography is available upon request and a summary of key secondary data sources is available in Appendix 5. DATA LIMITATIONS, STAFF CAPACITY In addition to some of the limitations outlined in the sections above, it is important to acknowledge explicitly that data were not always available for all desired metrics, and decisions about which data to include were made at times based on data availability or suitability. Gallatin County is a relatively large geographic area with a relatively small population which puts natural limitations on types of data available. Further, staff capacity was limited, and exhaustive pursuit of datasets was not always possible. In acknowledging limitations, it is equally important to note that staff and interns working on the project devoted their greatest possible efforts and available time to the project which has resulted in a robust and rigorously produced snapshot of health in Gallatin County. Regardless of such limitations and capacity constraints, this report is an effective and valuable tool to understand health in Gallatin County. RELATIONSHIP OF SOCIAL DETERMINANTS OF HEALTH TO COMMUNITY ENGAGEMENT AND PROCESS DESIGN The places we live, work, and play influence our health in many ways. The World Health Organization defines the social determinants of health as: “The circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.”9 These factors are also recognized by the Centers for Disease Control and the U.S. Department of Health and Human Services which have each also adapted and adopted these concepts in their work.10 11 Figure 2 from the CDC depicts the five social determinants of health. 22 Figure 2: Social Determinants of Health To embed these determinants into the design of the assessment, the Core Group decided to recruit Community Committee members with a range of professional perspectives which relate to the domains of the social determinants of health. Then, to put these perspectives into action, the Community Committee members were asked to have an influential hand in the direction of the assessment at key points. Additionally, with an eye toward community engagement and communication, the Core Group developed and distributed project newsletters every other month for community partners and members to learn about the recent activities and next steps. Each newsletter contained information about how to submit questions. Also, community partners and community members were invited and encouraged to register to join any and all of the Community Committee meetings. At each of those meetings, the agenda set aside dedicated time for “Community Comment” from any partners or individuals who might want to provide comments or ask questions. 23 FINDINGS Findings from Gallatin County’s community health assessment are outlined below. The report will first explore data related to demographics and community context, followed by data on health outcomes and a variety of health factors. COMMUNITY PROFILE The purpose of the community profile is to provide contextual background on Gallatin County and its residents before exploring the community’s health-related indicators. To do so, this section will review basic demographic information about Gallatin County residents (e.g., population size, age and sex breakdowns, and race and ethnicity, among others) as well as metrics that help describe the community’s strengths and opportunities (e.g., employment, education, and environment, among others). DEMOGRAPHICS Demographic data provide a general description of the residents living in Gallatin County, Montana. Common data points used to describe demographics often include the total population size, sex/gender, age, and race and ethnicity. By understanding the demographic makeup of the population, public health efforts can better target subpopulations with specific needs. PRESENTATION OF DEMOGRAPHICS DATA As of 2022, a postcensal estimate of Gallatin County’s population was estimated to be approximately 124,85712 residents, most (52%) of which are males. The most common age group among Gallatin County residents was between ages 20 to 24 years, making up about 12% of the county’s total population. The next largest age groups were 25 to 29 years (9%) and 30 to 34 years (8%). 10,000 8,000 6,000 4,000 2,000 0 2,000 4,000 6,000 8,000 10,000 0-4 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 Population sizeAge groupFigure 3: Population of Gallatin County, MT by Age and Sex in 2018-2022 Males Females Source: UnitedStates Census Bureau, American Community Survey, 5-Year Estimate 24 According to the U.S. Census Bureau, to qualify as “urban” the area “must encompass at least 2,000 housing units or have a population of at least 5,000.”13 According to the 2020 census estimates, 65% of Gallatin County’s population resided within urban areas, which is an approximate 2% decrease since 2010. Comparatively 53% of Montana’s statewide population were estimated to live in urban territories, which is about 3% less than in 2010.14 15 As of 2020, an estimated 5% of Gallatin County’s residents were Hispanic or Latino, which is a 2% increase from 2010. Among Gallatin County’s non-Hispanic or Latino population, the majority (89.0%) of residents were White per 2020 census estimates, which is down approximately 6.1% from 2010. About 6.6% of the population reported being two or more races and 1.8% reported “other” race. 33.5%34.8% 66.5%65.2% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2010 2020Percent of populationYear Figure 4: Percent of Population Living in Urban and Rural Areas in Gallatin County, MT in 2010 and 2020 Rural population Urban population Source: UnitedStates Census Bureau Decennial Census 2.8% 97.2% 5.0% 95.0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Hispanic or Latino Not Hispanic or LatinoPercent of populationEthnicity Figure 5: Percent of Population by Ethnicity in Gallatin County, MT in 2010 and 2020 2010 2020 Source: United States Census Bureau Decennial Census 25 Below (Figures 7 and 8) are county-level census data between 2018 and 2022. According to the census estimates, 96% of Gallatin County residents were English speakers compared to 4% who were non- English speakers. Among non-English speaking residents, the most common (59%) language was Spanish, followed by Asian and Pacific Island languagesi at about 25%. Approximately 7% of non-English speakers in Gallatin County reported speaking other Indo-European languagesii and 9% reported speaking languagesiii other than those previously listed. i Asian and Pacific Island languages: Chinese, Japanese, Korean, Hmong, Vietnamese, Khmer, Thai, Lao, or other Tai-Kadai languages, Burmese, Karen, Turkish, Uzbek, Tagalog, Filipino, Ilocano, Samoan, Hawaiian, or other Austronesian languages. (U.S. Census Bureau. About Language Use in the U.S. Population. Retrieved from: https://www.census.gov/topics/population/language-use/about.html) ii Other Indo-European languages: French, Haitian, Italian, Portuguese, German, Yiddish, Dutch, Greek, Russian, Polish, Serbo-Croatian, Ukrainian, Czech, Bulgarian, Armenian, Persian, Gujarati, Hindi, Urdu, Punjabi, Bengali, Nepali, Marathi, Telugu, Tamil, Malayalam, Kannada. (U.S. Census Bureau. About Language Use in the U.S. Population. Retrieved from: https://www.census.gov/topics/population/language-use/about.html) iii Other languages: Navajo, other Native languages of North America, Arabic, Hebrew, Amharic, Somali or other Afro-Asiatic languages, Yoruba, Twi, or other languages of Western Africa, Swahili or other languages of Central/Eastern/Southern Africa, and other unspecified languages. (U.S. Census Bureau. About Language Use in the U.S. Population. Retrieved from: https://www.census.gov/topics/population/language-use/about.html) 95.1% 1.9%0.7%1.1%0.9%0.3%0.1% 89.0% 6.6%1.8%1.2%0.9%0.4%0.1%0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% White Two or More Races Other Race Asian American Indian and Alaska Native Black or African American Native Hawaiian & Other Pacific IslanderPercent of populationRace Figure 6: Percent of non-Hispanic Population by Race in Gallatin County, MT in 2010 and 2020 2010 2020 Source: UnitedStates Census Bureau Decennial Census 26 An estimated 96% of Gallatin County residents were born in the United States compared to 4% who were born in other countries. Among those born in the United States, 38% were born in Montana and 62% were born in other states/territories. Among residents born outside of the United States, 49% were naturalized citizens. 96% 4% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% English speaking Non-English speakingPercent of populationLanguage Figure 7: Languages Spoken at Home by Percent of Population in Gallatin County, MT in 2018-2022 Source: UnitedStates Census Bureau, American Community Survey, 5-year Estimate 59% 25% 7%9% 0% 10% 20% 30% 40% 50% 60% 70% Spanish Asian and Pacific Island languages* Other Indo-European languages** Other languages***Percent of non-English speakersLanguage Figure 8: Languages Spoken at Home by Percent of non-English-speakers in Gallatin County, MT in 2018-2022 Source: UnitedStates Census Bureau, American Community Survey, 5-year Estimate 27 NARRATIVE OF DEMOGRAPHICS TOPICS Gallatin County has an overall young population of residents which mostly (65%) reside in “urban” areas, classified by U.S. Census Bureau by encompassing at least 2,000 housing units or a population of 5,000 people.16 The majority (95%) of residents are non-Hispanic or Latino, of which 89% identify as White, 6.6% identify as two or more races, and 1.8% identify as “other races”. The remaining 2.6% of the non- Hispanic population identifies as Asian (1.2%), American Indian or Alaska Native (0.9%), Black or African American (0.4%), or Native Hawaiian or Other Pacific Islander (0.1%). The primary language spoken among residents is English (96%); among the 4% of non-English speaking residents, Spanish is the most common language (59%) followed by Asian and Pacific Island languages (25%). An estimated 96% of Gallatin County’s residents were born within the United States, of which 38% were originally born in the state of Montana. Among the 4% of residents born outside of the US, approximately 49% are considered naturalized citizens. COMMUNITY CONTEXT The community context provides a foundational understanding of the broader conditions and characteristics that shape health outcomes, including aspects such as population demographics, socioeconomic status, and physical and social environment. WHAT IS THE PURPOSE OF THIS TOPIC AND WHAT DO WE WANT TO KNOW? The community context section will review information which provides general insight into what life in Gallatin County is like for residents, including many indicators which have greatly shifted in recent years and have had impact on the overall health and well-being of the population. 96% 4% 38% 62% 49%51% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Native-born Foreign-born Montana Other state/territory Naturalized citizen Not a U.S. citizen Total population Born in United States Born outside of United StatesPercent of populationFigure 9: Place of Birth and Citizenship Status among Residents in Gallatin County, MT in 2018-2022 Source: United States Census Bureau, American Community Survey, 5-year Estimate 28 BRIEF INTRODUCTION OF METRICS The community context section is intended to provide background information that broadly describes Gallatin County. It will include metrics related to the education, employment, job industries, income, and poverty levels. This section also will provide a brief review of the county’s environment by looking at data related to housing and population growth. WHAT DID WE LOOK AT? Education is acquiring knowledge and skills within a formal learning environment. This is inclusive of the United States public education system, from elementary school through college and university systems. Education will be reviewed in terms of educational attainment among adults at the county, state, and national levels, as well as trends in the school drop-out rate among students from middle to high school in Gallatin County. Employment refers to the exchange of time and labor for monetary compensation. The common expectation is that, depending on household size, individuals should be able to balance the income generated and the cost of daily living in a community when employed in one local, full-time job. The employment metrics review the annual unemployment rate at the county, state, and national levels over time as well as differences in the labor force participation rates by sex and child status among Gallatin County residents. Income is dollars earned by the exchange of labor through employment and/or dollars earned through investments. Poverty occurs when the amount of income is insufficient to cover certain cost of living standards. The U.S. government’s poverty level for a family of four was $30,000 in 2023.17 To understand how income levels have changed over time, county-level data from 2013 to 2022 is included with comparisons to state and national income levels. Health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. Similar to a healthy behavior, health literacy allows individuals to have more autonomy in impacting their own health.18 Limited local data related to health literacy was readily available, so a narrative highlighting general literacy and numeracy levels is included in the report instead. Housing is a complex factor. A housing unit is a house, an apartment, a mobile home, a group of rooms, or a single room that is occupied (or if vacant, is intended for occupancy) as separate living quarters.19 To evaluate housing in Gallatin County, the assessment explored data related to the value of owner- occupied housing units in the county compared to state and national levels. Additional housing data are included further in the report (in the Social and Economic Factors and Environmental Factors sections). Population growth involves changes in the population of a defined geographic area over time. To understand how Gallatin County’s population has changed, this section reviews data related to the county’s population over time, the annual percent change in population over time compared to statewide estimates, as well as population growth projections through 2040. 29 WHY WE LOOKED AT IT The community context topics were selected by the Core Group. The group determined these topics to be contextually relevant to the health of Gallatin County’s residents. WHAT PUBLIC HEALTH KNOWS ABOUT THE IMPORTANCE OF THIS To identify and address potential health inequities, public health researchers seek to understand any cultural and systematic differences that may exist among various strata of the population (e.g., age groups, races and ethnicities, and sexes, among others). By researching and understanding the potential differences that exist, public health practitioners can identify health disparities, prioritize health needs, and design targeted public health interventions that are tailored to the specific conditions and needs of the community. BRIEF NARRATIVE (LINKS TO SOCIAL DETERMINANTS OF HEALTH) Based on the contextual information presented below, Gallatin County has an overall educated population which also is reflected in consistently lower unemployment rates and higher median household income than statewide and national estimates. The population is growing quickly compared to many other parts of the state and country, which increased sharply (5%) in 2020 after the COVID-19 pandemic began and introduced a new subset of the U.S. population that could now work remotely. The rapid population growth is likely partly contributing to the housing burden felt by many around the county. Gallatin County has a considerably higher proportion of housing which costs $300,000 or more, and especially housing costing $500,000 or more (Figure 17). Although data reviewing income, employment, and other contextual information highlights several strengths of Gallatin County and its residents, there remain large disparities among the population which contribute to inequities in health experiences and outcomes. Data showing the impacts of social determinants of health on negative health outcomes is well-documented.20 21 22 Therefore, it is crucial to consider non-medical factors (such as safe and affordable housing, job opportunities, and access to nutritious foods) which also have an impact on health and well-being. FRAMING TOPIC FROM THE LITERATURE By evaluating the differences that exist between subpopulations, public health can progress toward achieving overall health equity, a state in which everyone has fair opportunities to attain their highest level of health.23 In order to identify health disparities, it is crucial to first understand what cultural and/or contextual differences exist within a population (such as differences within educational attainment, income levels, race and ethnicity) and whether health factors and outcomes like morbidity and mortality vary between the subpopulations. LOCAL DATA DISCUSSION The community context data indicators all are derived from existing secondary sources (e.g., United States Census Bureau and the Montana Department of Labor and Industry, among others). 30 EDUCATION Individuals with higher education levels are more likely to live healthier and longer lives.24 The CDC notes a clear association between health disparities and inequities in education, stating that compared to those with higher education levels, individuals with less education are more likely to participate in negative health behaviors and/or experience negative health outcomes like chronic conditions or unintentional injury.25 Several studies have displayed associations between lower educational attainment and increased risk of cardiovascular disease.26 27 28 On average, Gallatin County has a much larger proportion of adults that possess a bachelor's degree or higher than both the statewide and national estimates. Census data indicated that as of 2022, 53% of Gallatin County adult residents had a bachelor's degree or higher, compared to 34% of adults in both Montana and the United States. Several studies have shown that adults who do not complete high school are more likely to have poor health and subsequently die prematurely from preventable conditions.29 30 31 In Gallatin County, an average of 1.7% of students have dropped out before completing high school between 2014 and 2023. This is significantly lower than Montana’s statewide school dropout rate of approximately 2.4% in the same nine-year period. Of the nine years of available data, Gallatin County’s highest dropout rate was observed during the 2018-2019 school year at a level of approximately 2.1% while the lowest rate was observed during the 2016-2017 school year at about 1.4%. 2% 18% 27% 53% 6% 28%33%34% 11% 26%28% 34% 0% 10% 20% 30% 40% 50% 60% Less than high schoolgraduate High school graduate orequivalency Some college or associate'sdegree Bachelor's degree or higherPercent of adults aged 25+Educational level Figure 10: Educational Attainment among Adults Aged 25+ Years in Gallatin County, MT, Statewide, and the United States in 2018-2022 Gallatin County Montana United States Source: UnitedStates Census Bureau, American Community Survey, 5-year Estimate 31 EMPLOYMENT According to data from the Montana Department of Labor and Industry, the three most prominent job industries in Gallatin County in 2023 were accommodation and food services, retail trade, and construction. Among all 22 industries highlighted by the Department of Labor and Industry, accommodation and food services made up 15% of all jobs, retail trade made up approximately 13%, and construction accounted for 11% of all jobs in the county. Comparatively, the three largest industries in the state of Montana were healthcare and social assistance (14%), retail trade (12%), and accommodation and food services (12%).32 0% 1% 2% 3% 4% 5% 2014-2015 2015-2016 2016-2017 2017-2018 2018-2019 2019-2020 2020-2021 2021-2022 2022-2023Percent of studentsSchool year Figure 11: Middle through High School Drop-out Rate by School Year in Gallatin County, MT and Statewide from 2014 to 2023 Gallatin County MontanaSource: Montana Office of Public Instruction (OPI) 10,380 9,338 7,436 7,261 5,479 0 2,000 4,000 6,000 8,000 10,000 12,000 Accommodation and food services Retail trade Construction Health care and social assistance Professional, scientific, and technical services Number of jobsIndustryFigure 12: Top Five Largest Job Industries in Gallatin County, MT as of 2023 Source: Montana Department of Labor & Industry (DLI) 32 Annual unemployment rates at the local level appear to follow similar trends to what is observed both state and nationwide. As of 2023, Gallatin County’s unemployment rate was estimated at about 2.1%, which was just slightly lower than in Montana and the United States (3.0% and 3.6%, respectively). For Gallatin County, the highest rate of unemployment since 2000 was observed in 2009 when it reached about 7.0%; whereas the highest rates statewide and nationally were seen in 2010, reaching 7.2% in Montana and 9.6% in the United States. All three population levels experienced the lowest unemployment rates in 2022, dropping to 1.9% locally, 2.6% throughout Montana, and 3.6% across the United States. Historically, women have made up less of the United States workforce compared to men.33 Some of the factors contributing to this disparity include women receiving lower wages and fewer workforce benefits than men.34 This workforce disparity is even further apparent when considering women caring for children less than 18 years of age.35 In Gallatin County, census data indicated that adult males participated in the workforce at an average rate of 87% between 2015 and 2022. Data prior to 2015 were unavailable because the census survey previously was not capturing employment information related to women with children less than 18 years old. During the same 2015-2022 period, adult female labor force participation averaged about 79% compared to adult females with children under 18 years old averaging about 73%. Additional county-level census data from the 2015-2022 American Community Survey indicated that the average unemployment rate among adult females was 3.2%, and females with their own children under 18 years old experienced an average 3.7% unemployment rate.36 Comparatively, males experienced an average of 2.9% unemployment during the same eight-year period. The unemployment rate includes people who do not have a job, are actively looking for work in 0% 2% 4% 6% 8% 10% 12%Unemployment rateYear Figure 13: Annual Unemployment Rate over Time in Gallatin County, MT, Statewide, and the United States from 2000 to 2023 Gallatin County Montana United States Sources: Montana Department of Labor and Industry Local Area Profiles and United States Bureau of Labor Statistics 33 the prior four weeks and currently are available for work.37 This does not measure the percent of people with a job, which is captured in the labor force participation rate.38 INCOME Per census data, the median annual household income has been slowly increasing over time at the local, state, and national levels between 2013 and 2022. Within Gallatin County, median annual household income rose from $52,833 in 2013 to $83,434 in 2022, indicating a 58% increase while inflation only increased by 27% during the same 10-year period.39 Comparatively, the median annual household income only rose 44% statewide and 42% nationwide during the same period. The 10-year average of the median annual household income within Gallatin County is $63,676, which is approximately 5% higher than national income levels and 20% higher than statewide income levels. 88%88%87%88%88%87%87%87% 80%79%79%79%80%80%80%80%73%73%73%73%74%73%75%74% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2015 2016 2017 2018 2019 2020 2021 2022Participation rateYear Figure 14: Labor Force Participation Rate among Adults Aged 20-64 Years by Sex and Child Status in Gallatin County, MT from 2015 to 2022 Males Females Females with own children under 18 years Sources: United States Census Bureau, American Community Survey 5-year estimates 34 Demographic data from 2022 showed that Hispanic or Latino individuals in Gallatin County had a disproportionally higher rate of poverty compared to those who identify as White or two or more races. This percentage was documented as 20% compared to 24% in Montana and 17% across the US. This is the only demographic measured where Gallatin County was not comparable to or below that of Montana and/or the United States overall. $0 $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Dollar amount (adjusted annually for inflation)Year Figure 15: Median Annual Household Income in Gallatin County, MT, Statewide, and the United States from 2013 to 2022 Gallatin County Montana United States Source: UnitedStates Census Bureau, American Community Survey, 5-year Estimates 8% 13% 6% 11%10%10% 15% 20% 13%12%13%11%13% 11% 15% 24% 16% 12%11%11% 14% 10% 15%17% 0% 5% 10% 15% 20% 25% 30% Under 18 years 18 to 64 years 65+ years Males Females White alone Two or more races Hispanic or Latino origin (of any race) Age Sex RacePercent of populationFigure 16: Percent of Population below the Poverty Line by Age Group, Sex, and Race in Gallatin County, MT, Statewide, and the United States in 2022 Gallatin County Montana United States Source: UnitedStates Census Bureau, American Community Survey, 1-year Estimate 35 HEALTH LITERACY According to the CDC, health literacy can be divided into two categories: personal health literacy, or “the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others;” and organizational health literacy, which is “the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.”40 A 2003 study among 19,000 adults reported that only an estimated 12% of U.S. adults had proficient health literacy, indicating that the remaining 88% of adults potentially lacked the health literacy skills necessary to maintain their individual health and prevent disease.41 The same study detailed that limited health literacy was found among all races and ethnicities, highlighting that the proportion of U.S. adults with basic or below basic health literacy ranges between 28% of White adults and 65% of Hispanic adults.42 A similar survey was conducted in 2017 to evaluate the nation’s progress in adult skills related to literacy, numeracy, and problem solving in technology-rich environments.43 Although the data does not specifically measure health literacy, understanding overall literacy levels can provide important context when evaluating health experiences and outcomes. This is because individuals who are proficient in literacy better understand and utilize information related to their health.44 Results from the 2017 survey indicated that the White population in the United States scored approximately 12% higher than the Hispanic population in terms of literacy and about 16% higher than the Black population. When measuring numeracy, the White population scored about 22% higher than the Black population and 17% higher than the Hispanic population. Of the three highlighted race/ethnicity groups, however, the Hispanic population was the only one to improve in both literacy and numeracy proficiency between the 2012 and 2017 surveys. The Program for the International Assessment of Adult Competencies combined the literacy results with data from the Census Bureau’s American Community Survey to create model-based estimates at the county-level.45 Literacy and numeracy estimates are grouped into three levels,iv with level one iv ≤ Level 1: Adults at this level can be considered at risk for difficulties using or comprehending print material. Adults at the upper end of this level can read short texts, in print or online, and understand the meaning well enough to perform simple tasks, such as filling out a short form, but drawing inferences or combining multiple sources of text may be too difficult. Adults who are below Level 1 may only be able to understand very basic vocabulary or find very specific information on a familiar topic. Some adults below Level 1 may struggle even to do this and may be functionally illiterate. Level 2: Adults at this level can be considered nearing proficiency but still struggling to perform tasks with text- based information. Such adults may be able to read print and digital texts, relate multiple pieces of information within or across a couple documents, compare and contrast, and draw simple inferences. They can navigate in a digital environment to access key information, such as finding two main benefits of one product over another. However, more complex inferencing and evaluation may be too difficult. ≥ Level 3: Adults at these levels can be considered proficient at working with information and ideas in texts. They have a range of higher literacy skills from the ability to understand, interpret, and synthesize information across 36 considered the least proficient, and level three considered the most proficient. Based on their modeling, 63% of Gallatin County adults were at or above level three literacy proficiency, which was higher than the state’s estimate of 51% of adults. Similarly, the county also scored higher than the state related to numeracy proficiency, where about 53% of county adults were at or above level three compared to 40% of the state. Both the literacy and numeracy estimates in Gallatin County found a statistically higher percentage of adults at or above level three. Additional data from the 2016 Behavioral Risk Factor Surveillance System in 17 states highlighted important differences that exist within various other demographic factors. Compared to adults over the age of 65 years, most other age groups were approximately 15% more likely to be above the median health literacy level (youth aged 18-24 years were the only exception, where an estimated 14% were more likely to have lower health literacy compared to adults over 65). Different levels of income had a very strong association to health literacy, with Americans earning more than $75,000 annually were 70% less likely to have lower health literacy.46 Relative to White adults, Asian Americans and Pacific Islanders/Native Hawaiians were estimated to be about 50% more likely to have lower health literacy.47 Health literacy has been deemed a national priority, first highlighted in 2000 by the Department of Health and Human Services through it’s Healthy People 2010 goals (and also carried over into the Healthy People 2020 and Healthy People 2030 goals) and again in the 2003 Institute of Medicine report.48 Due to its critical role in public health, the CDC has created a Health Literacy Action Plan which outlines national strategies aimed at improving health literacy.49 HOUSING Per the five-year census estimates as of 2022, compared to both Montana and the United States, Gallatin County contained a much higher percentage of owner-occupied units valued at $300,000 or more. This was especially apparent when considering homes valued at $500,000 or more. In Gallatin County, an estimated 52% of owner-occupied units are valued at $500,000 or more, compared to only 22-23% of units found in Montana and the US. This also means that Gallatin County had a much lower percentage of more affordable housing options available; only 17% of the owner-occupied units county- wide were valued at less than $300,000 compared to 50% throughout the state and 45% nationwide. multiple, complex texts to the ability to evaluate the reliability of sources and infer sophisticated meanings and complex ideas from written sources. (Program for the International Assessment of Adult Competencies. Retrieved from: https://nces.ed.gov/surveys/piaac/skillsmap/) 37 The number of tourist homes licensed in Gallatin County increased from 39 in 2017 to 349 in 2024; however, not all of the tourist homes licensed in a particular year continued to operate in subsequent years. As of August 19, 2024, 855 active tourist home licenses existed in Gallatin County. The City of Bozeman passed Ordinance 2149, effective on December 14, 2023, which prohibited tourist homes not owner-occupied at some point during the year. The ordinance allowed a six-month period for applicants to become licensed through Gallatin County and inspected by other entities (e.g., Bozeman Fire Department). The ordinance resulted in a large number of applications being submitted to GCCHD in early 2024, and subsequently the large increase in licensed tourist homes in 2024. 2%3%2%1% 9% 31% 39% 13% 6%6%7%9% 22% 29% 17% 5%6%8%9%11%11% 24% 17% 6% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% Less than $50,000 $50,000 to $99,999 $100,000 to $149,999 $150,000 to $199,999 $200,000 to $299,999 $300,000 to $499,999 $500,000 to $999,999 $1,000,000 or morePercent of unitsHome value Figure 17: Value of Owner-occupied Units* in Gallatin County, MT, Statewide, and the United States in 2018-2022 Gallatin County Montana United Sates Source: UnitedStates Census Bureau, American Community Survey, 5-year Estimate*Units includes: single family homes, apartments, condominiums, mobile homes, boats, recreational vehicles, vans 38 POPULATION GROWTH Census population-based data between 2013 and 2022 are described in the two figures below. Out of the 56 counties in Montana, Gallatin County was the second most populated in the state. Gallatin County’s population was estimated at about 124,857 residents, which is an approximate 35% increase from 10 years prior in 2012 when the population was 92,627. On average the county’s annual population has increased 3% over the 10-year period, with the largest percent change (5%) in population size observed in 2020. Statewide, however, Montana only has experienced an average of 1% annual growth during the same 10-year period, with the largest increase in population size observed between 2020-2022 at a rate of about 2% each year. 39 119 76 69 100 185 201 349 0 50 100 150 200 250 300 350 400 2017 2018 2019 2020 2021 2022 2023 2024Number of homesYear Figure 18: Number of Licensed Tourist Homes Registered per Year in Gallatin County, MT, from 2017 to 2024* Source: Internal Gallatin City-County Health Department Data, Environmental Health Services Division* As of August 19, 2024 39 Population projections are made using existing population-based data and trends that allow researchers to plan for future adaptations that may be necessary to sustain a large shift in the population size. Based on projections by the Montana Department of Commerce, Gallatin County is expected to experience a 34% increase in population size from 2022, reaching approximately 167,528 residents as of 2040. Comparatively, the state of Montana’s population is only expected to increase by 9% by 2040, reaching about 1,226,445 residents statewide. 97,629 104,999 111,878 119,585 124,857 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022Population Year Figure 19: Population over Time in Gallatin County, MT from 2013 to 2022 Source: United States Census Bureau, Postcensal Estimates 2% 3% 4% 4%4% 3% 2% 5% 3% 2% 1%1%1%1%1% 1%1% 2%2%2% 0% 1% 2% 3% 4% 5% 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022Percent changeYear Figure 20: Percent Change in Population in Gallatin County, MT and Statewide from 2013 to 2022 Gallatin County Montana Source: United States Census Bureau, Postcensal Estimates 40 HEALTH OUTCOMES INTRODUCTION The health outcomes section of the Community Health Assessment reviews data related to the quality of life and length of life among Gallatin County residents. Specifically, quality of life will include metrics related to morbidity (diseases or conditions causing an unhealthy state of well-being) and length of life will cover metrics associated with mortality (causes of death). DISCUSSION OF RELATIONSHIP BETWEEN MORBIDITY AND MORTALITY SECTIONS Although the morbidity and mortality sections will be reviewing separate datapoints, the two topics are highly intertwined. For example, the morbidity data reviews the prevalence of various chronic conditions among Gallatin County residents, such as cancer, diabetes, or cardiovascular disease, all of which also are among the leading causes of mortality as well. Similarly, the morbidity section will cover rates of infectious diseases, though it’s worth noting that only one disease (COVID-19) is among a leading cause of mortality. Morbidity and mortality go beyond the “typical” diagnosed conditions and diseases; however, much of the data will also be reviewing mental health status and how it relates to overall morbidity and mortality. Throughout the United States, poor mental health has become a rapidly growing public health concern. In fact, data from the National Institute of Mental Health indicates that in 2021 an estimated 20% of adults and 49.5% of adolescents in the United States had a mental illness.50 Data has shown a clear relationship between poor mental health and increased risk of chronic conditions,51 52 53 which account for the majority of leading causes of death worldwide. 145,965 151,235 155,291 158,524 161,179 163,501 165,570 167,528 130,000 135,000 140,000 145,000 150,000 155,000 160,000 165,000 170,000 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040Population Year Figure 21: Population Growth Projections through 2040 in Gallatin County, MT Source: eRemi Montana State and County Population Projection by Gender, Race and Age from Regional Economic Models Incorporated (REMI) 41 DISCUSSION OF IMPACTS COMMUNITY PROFILE AND HEALTH FACTORS HAVE ON HEALTH OUTCOMES Health outcomes like morbidity and mortality are greatly influenced by both medical and nonmedical factors. In recent years, public health has shifted to center its essential services around the goal of health equity. To achieve equity, the CDC states that public health services must “actively promote policies, systems, and overall community conditions that enable optimal health for all and seek to remove systemic and structural barriers that have resulted in health inequities.”54 Demographic factors like race, language, or sex have a long and demonstrated history of influencing health outcomes in a variety of ways. For example, cardiovascular disease, which is the leading cause of mortality, disproportionately impacts minority populations (particularly Black residents) within the United States.55 56 Some nonmedical factors are beyond the individual level, however, and create barriers which systematically cause health inequities. Within the health factors section, data highlight a variety of differences that exist between subpopulations of Gallatin County. In particular, race and ethnicity data among emergency department visits per 1,000 Medicare beneficiaries (Figure 87) indicates that the rate of visits is disproportionately impacted by many of the non-White populations (particularly American Indians or Alaska Natives) within Gallatin County. MORBIDITY Morbidity refers to the state of having a disease or condition or experiencing symptoms due to a disease or condition, as well as the amount of disease occurring in a population.57 Common topics used to describe a population’s morbidity can include overall health status, the prevalence and/or incidence of chronic conditions or infectious diseases, the prevalence of mental/behavioral health issues, and maternal/child health. WHAT IS THE PURPOSE OF THIS TOPIC AND WHAT DO WE WANT TO KNOW? It is crucial to explore and track data related to morbidity because it provides insight into the community’s overall well-being and helps to identify potential opportunities for public health intervention. Many factors contributing to morbidity and mortality are preventable (e.g., physical activity, diet, sleep) and the appropriate interventions may help lower rates over time. It is important, however, to recognize that many nonmedical factors are unavoidable for some. BRIEF INTRODUCTION OF METRICS In order to evaluate morbidity among Gallatin County residents, the community health assessment explores metrics related to overall health status, prevalence of chronic conditions, incidence of communicable (infectious) diseases, mental health status, and maternal and child health. WHAT DID WE LOOK AT? Adult health status is a general measure of how individuals over the age of 18 perceive their health. It is typically self-reported and is categorized by adults indicating whether their overall health is “good or better” or “fair or poor.” Health status also is measured by estimating the number of days in the past 42 month when physical health was not good (0 days, 1-13 days, or 14+ days). Data are derived from the CDC’s Behavioral Risk Factor Surveillance System and include adults in Gallatin, Madison, and Park Counties between 2016 and 2021. Chronic diseases are conditions that last one year or more and require ongoing medical attention and/or limit activities of daily living.58 Chronic conditions are associated with the greatest number of illnesses, disabilities, and deaths in the United States.59 To explore the level of chronic disease in Gallatin County, the report will review data related to cancers, obesity, diabetes, and disability. Communicable diseases are illnesses which are caused by infectious agents (sources). Some diseases are contagious (spread from person to person) while others are transmitted via infectious agents carried in the air, water, food, soil, or through vectors (biting insects or animals).60 Within the community health assessment report, communicable disease data will include more common conditions such as COVID-19, influenza, sexually transmitted infections, and vaccine-preventable diseases. Mental health refers to all aspects of well-being, such as individuals’ emotional, psychological, and social health. It also affects how we think, feel, and act, and helps us determine how we handle stress, relate to others, and make choices.61 Mental illnesses include a broad range of disorders, often varying in severity, and are estimated to impact one-in-five adults and 49.5% of adolescents.62 In order to evaluate the mental health status among Gallatin County residents, the assessment will delve into data on general self-reported mental health status, Help Center call types, and youth-related indicators. Additional mental health data will be reviewed in the Health Factors section of the report. Maternal and child health is a public health subfield that began by focusing on a specific population (mothers and children), rather than a method (as with epidemiology) or skillset (as with health policy).63 Maternal and child health is a focus of public health practice because it directly impacts the health and well-being of both current and future generations. The community health assessment will explore data related to the prevalence of adverse prenatal outcomes as well as the percent of mothers who smoke during pregnancy. Unfortunately, data at the county level was difficult to obtain. Additional maternal and child health data related to mortality are included later in the report. WHY WE LOOKED AT IT The topics included within the morbidity section were determined by the Core Group. Morbidity refers to any deviation from an overall healthy state. Morbidity data are crucial to better identify and address community needs, evaluate progress over time, and work toward an overall healthier population. WHAT PUBLIC HEALTH KNOWS ABOUT THE IMPORTANCE OF THIS Some of the most common causes of morbidity and mortality are associated with chronic conditions, which have been the case within the United States since the early 1900s.64 An estimated 90% of annual U.S. health expenditures are spent toward people with chronic and mental health conditions, many of which can be prevented with the appropriate interventions.65 Beyond chronic conditions, communicable diseases also pose public health threats and greatly impact both morbidity and mortality. The CDC reports that in 2019, approximately 10.2 million physician office visits were attributed to infectious or 43 parasitic diseases.66 Lastly, indicators related to maternal and child health often are used to gauge overall community health because they directly impact the health and well-being of both current and future generations.67 BRIEF NARRATIVE EXPOSITION (LINKS TO SOCIAL DETERMINANTS OF HEALTH) It is widely documented that our health is influenced by a number of factors (both medical and nonmedical) which impact our overall quality of life.68 69 70 Many of the health inequities that people experience can be attributed to nonmedical factors like geography, ethnicity, language, or sexual orientation, among others.71 FRAMING TOPIC FROM THE LITERATURE Morbidity data provide valuable insight into the level of illness occurring in a population. When evaluated in association with demographic and lifestyle factors, researchers can identify whether differences exist between subgroups and if certain populations are at increased risk of severe morbidity and mortality compared to others. LOCAL DATA DISCUSSION The data used to inform the morbidity indicators were derived from internal data tracking and existing secondary sources. Differences between subgroups were evaluated where data were available to do so. Based on the several insights described below, morbidity outcomes clearly vary between different subgroups of Gallatin County’s population. While these insights highlight potential opportunities for targeted public health interventions, additional data is needed to understand the full impact of these differences throughout the community. ADULT HEALTH STATUS According to data from the Behavioral Risk Factor Surveillance System, 8% of adults (aged 18 years and older) in Gallatin, Madison, and Park Counties reported being physically unhealthy for at least half of the last month (14+ days) in 2020-2021. This estimate is slightly (2%) down from the survey data from 2018- 2019 but 1% higher than in 2016-2017. The percent of adults in the Gallatin, Madison, and Park Counties that report being physically unhealthy between 1-13 days in the last month remained at about 23% between 2016 to 2019 and decreased slightly to 20% in 2020-2021. Overall, this indicator related to adult health status in Gallatin, Madison, and Park Counties has improved slightly over time. 44 Similar to the data above, the figure below represents data from a behavioral risk factor survey among adults in Gallatin, Madison, and Park Counties between 2016 and 2021. The data indicated that the percent of adults in the Gallatin, Madison, and Park Counties self-reporting a poor or fair health status had decreased by 2% over each of the two-year periods. This data aligns with the previous Behavioral Risk Factor Surveillance System metric, representing a slight improvement over the six-year period. CHRONIC CONDITIONS Chronic conditions continue to pose a severe threat to public health and are associated with the highest rates of morbidity and mortality worldwide.72 According to the five-year census estimates from 2022, an 23%23%20% 7%10% 8% 0% 5% 10% 15% 20% 25% 30% 35% 2016-2017 2018-2019 2020-2021Percent of populationYear Figure 22: Percent of Adults Self-reporting Physically Unhealthy Days in the Past Month Gallatin, Madison, and Park Counties, MT from 2016 to 2021 1-13 days 14+ days Source: BehavioralRisk Factor Surveillance System, Centers for Disease Control and Prevention 12% 10% 8% 0% 2% 4% 6% 8% 10% 12% 14% 2016-2017 2018-2019 2020-2021Percent of adultsYear Figure 23: Percent of Adults Ages 18 Years or Older Self-reporting Poor or Fair Health Status in Gallatin, Madison, and Park Counties, MT from 2016 to 2021 Source: BehavioralRisk Factor Surveillance System, Centers for Disease Control and Prevention 45 estimated 9.2% of the population in Gallatin County had some sort of disability (defined by the census as respondents reporting difficulty in any one of the following areas: hearing, vision, cognition, ambulation, self-care, or independent living).73 Looking into whether differences exist across various demographic characteristics (e.g., sex, race, ethnicity, age) allows public health researchers to identify potential disparities, understand the challenges across diverse groups, and develop and implement inclusive health prevention strategies.74 First, looking at differences between sexes, 9.4% of the male population in Gallatin County had a disability compared to about 8.9% of the female population. Race and ethnicity also vary among those with disabilities; within Gallatin County approximately 29.0% of the American Indian population and 18.3% of the Black population had a disability, compared to just 9.1% of the White population, and 5.6% of the Asian population. Among Hispanic or Latino residents in Gallatin County, an estimated 5.8% had a disability. Age also is recognized as one of the biggest disparities in disability prevalence; the CDC indicated that about 43.9% of people aged 65 years and older had a disability compared to other age groups.75 Among Gallatin County residents aged 75 years or older, 43.7% reported having at least one disability compared to about 23.3% of individuals aged 65 to 74 years and just 8.4% of 35- to 64-year-olds. Disability prevalence is similar among the age groups 5-17 years and 35-64 years (4.5% and 5.0%, respectively), and is the lowest (0.6%) among individuals aged less than 5 years old. 9.2% 9.4% 8.9% 29.0% 18.3% 9.1% 5.6% 5.8% 43.7% 23.3% 8.4% 5.0% 4.5% 0.6% 0%5%10%15%20%25%30%35%40%45%50% Overall Male Female American Indian Black White Asian Hispanic or Latino 75 or older 65-74 35-64 18-34 5 to 17 Under 5 Race and ethnicityAge group (years)Percent of population Figure 24: Percent of Population with a Disability by Age Group, Race/Ethnicity, Gender, and Overall in Gallatin County, MT as of 2022 Data Source:United States Census Bureau, American Community Survey, 5-year EstimatesGender 46 Among the 9.2% of Gallatin County residents who had at least one disabilityv (Figure 24), most (4.0%) report cognitive difficulty as of 2022; this is 0.7% higher than estimates in 2015 and represents the largest increase among the six disability types over the 7-year period. The next most common disability type in 2022 was ambulatory, impacting about 3.7% of disabled Gallatin County individuals, about 0.5% increased from 2015. Both hearing difficulty and independent living difficulty are estimated to impact about 3.4% of the disabled population. While the prevalence of hearing difficulty did not shift much from 2015, the percent of residents with independent living difficulties increased about 0.5%. Two of the less prevalent disability types included self-care difficulty (1.5%) and vision difficulty (1.4%), both of which have remained fairly steady over the 7-year period. According to age-adjusted data from the 2016-2020 state cancer profiles, an estimated 448 individuals per 100,000 residents in Gallatin County were reported to have cancer. This is similar, but slightly higher, than the nationwide incidence estimated at about 442 individuals per 100,000 residents but is lower than that which is reported across the state (457 per 100,000). Among Gallatin County residents only, males had a higher age-adjusted cancer incidence rate compared to females (504 per 100,000 and v Ambulatory disabilities refer to those having serious difficulty walking or climbing stairs. Cognitive disabilities are those due to a physical, mental, or emotional problem causing difficulty in remembering, concentrating, or making decisions. Hearing difficulties refer to those who are deaf or having serious difficulty hearing. Independent living difficulties are due to a physical, mental, or emotional problem causing difficulty doing errands alone such as visiting a doctor’s office or shopping. Self-care difficulties refer to those having difficulty bathing or dressing. Vision difficulties refer to those who are blind or having serious difficulty seeing, even when wearing glasses. (United States Census Bureau. Disability Glossary. Retrieved from https://www.census.gov/topics/health/disability/about/glossary.html#par_textimage_1149417898) 0% 1% 2% 3% 4% 5% 2015 2016 2017 2018 2019 2020 2021 2022Percent of populationYear Figure 25: Percent of Population by Disability Type in Gallatin County, MT from 2015 to 2022 Hearing difficulty Vision difficulty Cognitive difficulty Ambulatory difficulty Self-care difficulty Independent living difficulty Data Source:United States Census Bureau, American Community Survey, 5-year Estimates 47 401 per 100,000, respectively). Notable differences existed in the cancer incidence rates among age groups; residents aged 65 years and older were much more impacted than those below 65 years old (2,069 per 100,000 and 214 per 100,000, respectively). When evaluating differences among race and ethnicity data, cancer incidence rates were unavailablevi for the Black and Asian/Pacific Islander populations in Gallatin County. When comparing the age-adjusted incidence rates among cancer sites at the local, state, and national levels, Gallatin County had higher rates of prostate cancer, breast cancer, melanoma, bladder cancer, and non-Hodgkin lymphoma compared to both Montana and the United States. Gallatin County does, however, trend lower in both lung and colorectal cancer incidence rates compared to both Montana and the United States. The CDC suggests that cancer rates, like many other chronic conditions, can differ geographically due to variations that exist in social determinants of health across the nation.76 vi Data has been suppressed to ensure confidentiality and stability of rate estimates. Per the National Cancer Institute, counts are suppressed if fewer than 16 records were reported in a specific area-sex-race category. If an average count of 3 is shown, the total number of cases for the time period is 16 or more which exceeds suppression threshold (but is rounded to 3).vi (National Cancer Institute. State Cancer Profiles. Retrieved from https://statecancerprofiles.cancer.gov/incidencerates/index.php?stateFIPS=30&areatype=county&cancer=001&ra ce=28&sex=0&age=001&type=incd&sortVariableName=rate&sortOrder=default&output=0#results) 448 457 442 504 401 214 2,069 447 419 411 0 500 1,000 1,500 2,000 2,500 Gallatin CountyMontanaUnited StatesMaleFemale<6565+White, non-HispanicAmerican Indian/AlaskaNative, Non-HispanicHispanicLocation Sex Age group Race/EthnicityAge-adjusted rateper 100,000Figure 26: Age-adjusted Incidence Rate of All Cancer Sites per 100,000 Population in Gallatin County, MT, Statewide, and the United States in 2016-2020 Source: State Cancer Profiles, National Cancer InstituteGallatin County Montana United States 48 Data below represent age-adjusted obesity prevalence rates among adults in 2011 and 2021 compared at the local, state, and national levels. At all three geographical levels, obesity rates have increased over the 10-year period. As of 2021, an estimated 24% of Gallatin County adults were obese (BMI ≥30), representing a 9% increase from 2011. Similarly, statewide obesity rates have gone up by about 8% over the same period, increasing from 24% to 32%. Obesity prevalence in 2021 was highest at the national level, with age-adjusted estimates indicating 33% of adults were obese, representing a 6% increase from 2011. 149 141 44 32 29 25 24 20 131 134 28 48 31 26 23 18 111 127 23 54 32 27 19 19 0 20 40 60 80 100 120 140 160 Prostate (Males) Breast (Female) Melanoma Lung Colorectal Uterus (Females) Bladder Non-Hodgkin LymphomaAge-adjusted rate per 100,000Cancer site Figure 27: Age-adjusted Cancer Incidence Rates per 100,000 Population in Gallatin County, MT, Statewide, and the United States in 2016-2020 Gallatin County Montana United States Source: State Cancer Profiles, National Cancer Institute 49 Diabetes is among one of the top 10 leading causes of mortality at the county, state, and national levels according to 2022 data. Compared to Montana and the United States, Gallatin County had a lower age- adjusted diabetes prevalence rate, estimated to be approximately 4.7% according to 2021 data from the CDC. During the 10-year period, the prevalence rate has remained fairly consistent, fluctuating about 1.3% from the highest rate observed in 2016 (5.4%) to the lowest rate observed in 2019 (4.1%). 16% 24% 27% 24% 32%33% 0% 5% 10% 15% 20% 25% 30% 35% Gallatin County Montana United StatesPercent Location Figure 28: Age-adjusted Obesity Prevalence among Adults in Gallatin County, MT, Statewide, and the United States in 2011 and 2021 2011 2021 Source: BehavioralRisk Factor Surveillance System, Centers for Disease Control and Prevention 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021Age-adjusted prevalence Year Figure 29: Age-adjusted Diabetes Prevalence among Adults in Gallatin County, MT, Statewide, and the United States from 2011 to 2021 Gallatin County Montana United States Data Source:Centers for Disease Control and Prevention, U.S. Diabetes Surveillance System 50 COMMUNICABLE DISEASE Below (Figures 30, 31, and Table 2) are data collected by the Gallatin City-County Health Department through the Montana Infectious Disease Information System between March 2020 and July 2024. Since the first case of COVID-19 was reported in Gallatin County in March of 2020, there have been approximately 45,144 cases and 1,488 COVID-19-related hospitalizations reported among Gallatin County residents as of July 31, 2024. The maximum number of monthly cases were reported in January 2022 when the Omicron variant was introduced, reaching approximately 8,460 cases (averaging 273 cases per day). The minimum number of cases were in May 2020 with only five cases reported among residents. The maximum number of monthly hospitalizations occurred in November 2020 during which a reported 116 residents were hospitalized (averaging four hospitalizations per day). Comparatively, the minimum number of monthly hospitalizations was observed in May 2020, in which no residents were hospitalized. 0 20 40 60 80 100 120 140 Mar-20May-20Jul-20Sep-20Nov-20Jan-21Mar-21May-21Jul-21Sep-21Nov-21Jan-22Mar-22May-22Jul-22Sep-22Nov-22Jan-23Mar-23May-23Jul-23Sep-23Nov-23Jan-24Mar-24May-24Jul-24Number of hospitalizationsMonth/year Figure 30: Monthly COVID-19 Hospitalizations in Gallatin County, MT from March 2020 to July 2024 Source: Montana Infectious Disease Information System (MIDIS) 51 Table 2: Summary of Annual COVID-19 Cases, Hospitalizations, and Deaths Reported among Gallatin, County, MT Residents from March 17, 2020 to July 31, 2024 Metric 2020 2021 2022 2023 2024 (as of July 31) Total Cases 9,499 14,382 17,071 3,128 1,078 45,144 Hospitalizations 84 523 420 190 67 1,284 Deaths 46 64 23 7 † 141 †Data are suppressed due to <5 events According to the CDC, “age is the strongest risk factor for severe COVID-19 outcomes” like hospitalization or death.77 When evaluating county-level data by age group, it is apparent that older age groups are significantly more at-risk for severe outcomes associated with COVID-19. Despite making up only 3% of the county’s population, individuals aged 80+ years accounted for about 50% of the COVID- 19-related deaths and 23% of hospitalizations. Similarly, those aged 60-79 years make up 16% of the population, but accounted for 42% of hospitalizations and 39% of deaths related to COVID-19. 0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 Mar-20May-20Jul-20Sep-20Nov-20Jan-21Mar-21May-21Jul-21Sep-21Nov-21Jan-22Mar-22May-22Jul-22Sep-22Nov-22Jan-23Mar-23May-23Jul-23Sep-23Nov-23Jan-24Mar-24May-24Jul-24Number of casesMonth/year Figure 31: Monthly COVID-19 Cases in Gallatin County, MT from March 2020 to July 2024 Source: Montana Infectious Disease Information System (MIDIS) 52 Below (Figures 33 and 34) are internal health department data collected through the Montana Infectious Disease Information System between 2013 and 2024. Influenza season typically begins each year around the start of October and circulates fairly consistently until the end of May, although sporadic cases outside of the typical flu season do occur. Among the 11 years of available data, influenza rates were highest in the 2023-2024 season, infecting approximately 1,917 per every 100,000 residents in Gallatin County. The COVID-19 pandemic disrupted the typical influenza season with the sudden widespread implementation of precautions like masking, social distancing, and limited travel; no influenza cases were reported during the 2020-2021 season. Since then, however, cases have continued to rise and now exceed pre-pandemic levels. Seasonal influenza-related hospitalizations follow a similar trend; the highest rate was observed this most recent season in 2023-2024 where 61 per every 100,000 residents were hospitalized. During the 11-year period, a total of four influenza-related deaths have been reported among Gallatin County residents. 20% 40% 20%16% 3% 14% 47% 23% 13% 3%2% 11% 20% 42% 23% 0%1% 11% 39% 50% 0% 10% 20% 30% 40% 50% 60% 0-17 years 18-39 years 40-59 years 60-79 years 80+ yearsPercent Age group Figure 32: Proportion of Population and COVID-19 Cases, Hospitalizations, and Deaths by Age Group in Gallatin County, MT from March 2020 to July 2024 Population Cases Hospitalizations Deaths Source: Montana Infectious Disease Information System (MIDIS) 53 Among sexually transmitted infections, chlamydia is the most commonly reported across the United States.78 An estimated 1,172 cases were reported among Gallatin County residents from 2022-2023. Though slightly down from the case-count in 2020-2021, it represented an increase of 145 cases from data in 2018-2019. During the six-year period, gonorrhea incidence increased from 73 cases reported in 2018-2019 to about 113 in 2022-2023. HIV/AIDS cases remain fairly low in Gallatin County, with seven cases reported in 2022-2023 and five reported in 2018-2019. Syphilis cases have been increasing nationwide in the past several years; the CDC estimates an 80% increase in reported cases between 2018 and 2022.79 Gallatin County also experienced an increase in the number of syphilis cases; 38 843 718 516 915 921 1,428 1,551 0 953 1,711 1,917 0 200 400 600 800 1,000 1,200 1,400 1,600 1,800 2,000 Rate per 100,000Influenza season Figure 33: Seasonal Influenza Case Rate per 100,000 Population in Gallatin County, MT from 2013 to 2024 Source: Montana Infectious Disease Information System (MIDIS) † 49 40 58 39 37 24 0 † 49 61 0 10 20 30 40 50 60 70 Rate per 100,000Influenza season Figure 34: Seasonal Influenza Hospitalization Rate per 100,000 Population in Gallatin County, MT from 2013 to 2024 Source: Montana Infectious Disease Information System (MIDIS) † Rates are suppressed due to <20 events 54 (syphilis cases of all stages) were reported in 2022-2023, representing a 73% increase from the number of cases reported in 2018-2019. National data from the CDC indicated that in 2022, nearly half (49.8%) of chlamydia, gonorrhea, and syphilis cases were reported among young adults aged 15-24 years.80 According to data from 2018-2023, Gallatin County residents aged 18-29 years had the highest incidence of sexually transmitted infections, with an estimated 2,807 chlamydia cases and 165 gonorrhea cases reported. Residents aged 30-39 years had the next highest incidence, with 294 chlamydia cases and 73 gonorrhea cases reported in the six- year period. 1,027 73 5 22 1,200 92 †16 1,172 113 7 38 0 200 400 600 800 1,000 1,200 1,400 Chlamydia Gonorrhea HIV/AIDS Syphilis, all stagesNumber of casesYear Figure 35: Sexually Transmitted Infection Incidence in Gallatin County, MT from 2018 to 2023 2018-2019 2020-2021 2022-2023 Source: Montana Infectious Disease Information System (MIDIS)† Data are suppressed due to <5 events 189 2,807 294 95†165 73 36 0 500 1,000 1,500 2,000 2,500 3,000 0-17 years 18-29 years 30-39 years 40+ yearsNumber of casesAge group Figure 36: Chlamydia and Gonorrhea Cases by Age Group in Gallatin County, MT in 2018-2023 Chlamydia Gonorrhea Source: Montana Infectious Disease Information System (MIDIS)† Data are suppresseddue to <5 events 55 Among Gallatin County residents, pertussis (whooping cough) was the most commonly reported vaccine-preventable disease with an estimated 162 cases were reported between 2014-2023. Varicella (chickenpox) cases were the next most common vaccine-preventable disease with 55 cases reported in the 10-year period. Several other vaccine-preventable diseases were more sporadically reported; 40 mumps cases, 32 Streptococcus pneumoniae (invasive) cases, and 20 chronic Hepatitis B cases have been reported among Gallatin County residents. Additional vaccine-preventable diseases being monitored (not shown in the figure below) include Meningococcal disease, Haemophilus influenzae (serotype B), Hepatitis A (acute), and Hepatitis B (acute); however, due to low case counts (n<5), biannual data are suppressed for each of the three conditions. MENTAL HEALTH Similar to national trends,81 mental health issues account for a large portion of the county’s overall morbidity and mortality (Figure 50 and Figure 38). In addition to the mental health morbidity data, statistics related to suicide (Figures 50, 51, 52), substance use (Figures 54, 55, 56, 65, 66, 67, 68, 69, 90), and mental health care access (Figures 88, 89) are included within the report. Call center data from the Bozeman Help Center indicated that mental health was the most prevalent (44%) type of call received in 2022. Though this has not shifted from 2020 data, it represented a 15% increase from the percent of mental health-related calls in 2018 and a 31% increase from 2016. The next most common call types included relationships (31%) and suicide (25%) according to the most recent data. The rising prevalence of suicide-related calls is notable, increasing approximately 14% between 2020 and 2022. The less prevalent call-types as of 2022 included basic needs (12%) and substance abuse/addictions (11%). Additional call-types (not included below) include abuse (6%), health needs (5%), legal issues (4%), disaster (3%), and general (1%) as of 2022. 16 6 65 0 † 10 7 6 22 78 † 85 18 1212 †0 0 † 9 7 6 0 13 0 10 20 30 40 50 60 70 80 90 Varicella (Chickenpox)Hepatitis B, chronic Pertussis Mumps Streptococcus pneumoniae, invasiveNumber of casesVaccine preventable disease Figure 37: Vaccine Preventable Disease Incidence in Gallatin County, MT from 2014 to 2023 2014-2015 2016-2017 2018-2019 2020-2021 2022-2023 Source: Montana Infectious Disease Information System (MIDIS) † Data are suppressed due to <5 events 56 According to Behavioral Risk Factor Surveillance System data, the percentage of adults reporting feeling mentally unhealthy for 14 or more days in the last month has increased over time among residents of Gallatin, Madison, and Park Counties. An estimated 13% of adults in the area reported feeling mentally unhealthy for at least half of the last month in 2021-2022, which is a 6% increase from 2016-2017 estimates. 0 10 20 30 40 50 60 2012 2014 2016 2018 2020 2022Percent of callsYear Figure 38: Percent of Bozeman Help Center Calls by Type in Gallatin County, MT from 2012 to 2022 Relationships Mental health Suicide Substance abuse/addictions Basic needs Data Source: Bozeman Help CenterPercents exceed 100% because calls can be associated with multiple types 7% 12% 13% 0% 2% 4% 6% 8% 10% 12% 14% 2016-2017 2018-2019 2020-2021Percent of adultsYear Figure 39: Percent of Adults Reporting 14+ Mentally Unhealthy Days in the Past Month in Gallatin, Madison, and Park Counties, MT from 2016 to 2021 Data Source: BehavioralRisk Factor Surveillance System, Centers for Disease Control and Prevention 57 Below (Figures 40 and 41) are behavioral risk factor survey-based data from surveyed middle school (grades 7-8) and high school students in Gallatin County collected between 2017 and 2023. Based on the self-reported data, the percent of surveyed middle schoolers reporting that they did not attend school for at least one day in the past month due to safety concerns increased to 11% in 2023, which is a 3% rise from 2017. In the same seven-year period, the percent of surveyed middle school students reporting feeling so sad or hopeless almost daily for two or more consecutive weeks that they stopped doing some usual activities rose to 30% as of 2023, representing a 9% increase from 2017 and a 2% decrease from 2021. The same survey was issued to high school students and trends over time are similar to what is observed in middle schoolers. The percent of surveyed high schoolers self-reporting that they did not attend school for at least one day in the last month due to feeling unsafe was 11% in 2023, a 6% increase from 2021 and 7% increase from 2017. Between 2017 and 2023, the percentage of high school students reporting they felt so sad or hopeless almost daily for two or more consecutive weeks that they stopped doing some usual activities increased by 12%, estimated at 38% as of the most recent data. The same behavioral risk factor survey also captured data on the overall mental health status among middle school (grades 7-8) students and high school students. The related survey question was not included prior to 2021, resulting in only two years of data being available and presented below. Among surveyed students in Gallatin County, 13% of middle schoolers and 19% of high schoolers self-reported that their mental health was not good for most of the past month in 2023, representing a 2-3% decrease overall. However, the percent of students reporting poor mental health for the entire past month has increased by 1% at both school levels (9% among middle schoolers and 10% among high schoolers as of 2023). The indicators represented an overall increase in mental health concerns among surveyed middle and high school students in Gallatin County. 21% 31%32%30%26% 18% 40%38% 8%8%8%11% 4% 9%5% 11% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 2017 2019 2021 2023 2017 2019 2021 2023 Middle School High SchoolPercentFigure 40: Mental Health Indicators among Surveyed Middle and High School Students in Gallatin County, MT from 2017 to 2023 I have felt so sad or hopeless almost daily for 2+ weeks in a row that I stopped doing some usual activities I did not attend school for at least one day in the past month due to feeling unsafe Data Source: Youth Behavioral Risk Survey, Centers for Disease Control and Prevention 58 MATERNAL AND CHILD HEALTH Below are several indicators used to gauge the overall health status of women and children. Data related to maternal child health was overall sparse at the county-level. The prevalence of preterm births (live births that occur at <37 weeks) in Gallatin County was approximately 8.6% as of 2014-2018 data; this is only slightly (0.4%) lower than state-wide preterm birth prevalence. The county and state-level prevalence of low birth weight (live births <2500 grams) among newborns is similar; 7.6% of Gallatin County newborns are estimated to have low birth weight compared to 7.5% of newborns across the state. However, the percent of pregnant women receiving prenatal care in the first trimester in Gallatin County is about 5% higher than statewide. An estimated 76.7% of Gallatin County mothers receive prenatal care within the first trimester, compared to 71.7% of mothers in Montana. 15% 22% 8%9% 13% 19% 9%10% 0% 5% 10% 15% 20% 25% Middle School High School Middle School High School My mental health was not good for most of the past 30 days My mental health was not good for all of the past 30 daysPercent of surveyed studentsFigure 41: Percent of Surveyed Students Reporting Poor Mental Health during Most or All of the Past Month in Gallatin County, MT in 2021 and 2023 2021 2023 Source: Youth Risk Behavior Survey, Centers for Disease Control and PreventionData prior to 2021 is unavailable due to questions not being included in survey 59 According to the CDC, smoking during pregnancy increases the risk of severe outcomes such as premature birth, birth defects, or sudden infant death syndrome.82 At the county, state, and national levels, rates of smoking during pregnancy have decreased slightly each year between 2019 and 2022. Rates within Gallatin County are the lowest, with an estimated 3.6% of mothers smoking during pregnancy in 2022, a 2.1% decrease from data in 2019. National levels were similar, estimating that 3.6% of mothers within the United States smoked during pregnancy as of 2022, representing a 2.3% decrease over the four-year period. Statewide smoking rates among pregnant women were the highest among the three geographical levels; approximately 11.7% of mothers in Montana reported smoking during pregnancy in 2022, which was a 3.3% decrease since 2019. 28.3% 7.5% 9.0% 23.3% 7.6% 8.6% 0%5%10%15%20%25%30% No prenatal care in the first trimester Low birth weight Preterm births Percent of mothersIndicatorFigure 42: Prevalence of Adverse Prenatal Outcome Indicators in Gallatin County, MT and Statewide in 2014-2018 Gallatin County Montana Source: Healthy Montana Families 60 MORTALITY Mortality is typically measured as a rate by calculating the number of deaths (due to a specific cause) per every 100,000 residents in an area. To evaluate mortality within Gallatin County, this community health assessment will review data related to the leading causes of death, infant mortality, life expectancy, suicide, intentional or violence-related deaths, and unintentional/injury-related deaths. WHAT IS THE PURPOSE OF THIS TOPIC AND WHAT DO WE WANT TO KNOW? Mortality data are among some of the oldest public health indicators and continue to provide valuable insights into population-level data and inform public health strategies. In gathering, evaluating, and disseminating local mortality data (and the other report topics), we aim to identify and prioritize public health needs within the community, and collectively work with the community to address those needs. Tracking and evaluating mortality levels are crucial for efforts in preventing premature mortality, or death that occurs before the average age of death in a population (75 years in the US).83 The risk of premature mortality is typically associated with several modifiable factors, and although these factors can vary by disease, the most common factors include tobacco use, obesity, physical inactivity, and drinking alcohol/drinking in excess.84 By using upstream interventions and limiting or preventing modifiable risk factors, the overall risk of premature mortality can potentially be reduced in the community. BRIEF INTRODUCTION OF METRICS This community health assessment explored mortality levels within Gallatin County through a variety of metrics. The data will review the leading causes of mortality and premature mortality, infant birth and 5.7%4.9%4.2%3.6% 15.0%14.2% 13.0% 11.7% 6.0%5.5%4.6%3.7% 0% 2% 4% 6% 8% 10% 12% 14% 16% 2019 2020 2021 2022Percent of birthsYear Figure 43: Percent of Births to Mothers Who Smoked during Pregnancy in Gallatin County, MT, Statewide, and the United States from 2019 to 2022 Gallatin County Montana United States Sources: Montana Kids Count and Centers for Disease Control and Prevention, National Center for Health Statistics 61 death rates, maternal death rates, fatal overdoses, vehicle and other injury-related fatalities, and suicide. WHAT DID WE LOOK AT? Mortality rates among the leading causes of deaths are reported as the age-adjusted number of deaths due to a specific cause (e.g., COVID-19, cardiovascular disease) per 100,000 population per year. Many diseases, conditions, and causes of death are more prevalent among certain age groups than others; age adjustment allows researchers to compare morbidity and mortality rates without the influence of age variability in the population.85 Other than age groups, sex and race/ethnicity also are often associated with differences in mortality rates; these differences will be explored through cardiovascular disease mortality data among Gallatin County residents (Figure 46). Supplemental mortality data listing the leading causes of death by age group and race/ethnicity are provided in Appendix 1 (Tables 3 and 4). The report also evaluates premature mortality associated with the leading causes of death, reported as the number of years of potential life lost before age 75. Infant mortality is recognized by the CDC and other public health entities as a crucial indicator of the overall health of a society.86 Infant mortality is presented as a rate and indicates the number of infant deaths per 1,000 live births per year. Data related to infant birth rates over time compared to state and national levels also are included for comparison. Maternal mortality data at the county level were difficult to obtain, but prevalence is overall extremely low. A set of 17 statewide annual vital statistics reports highlight the crude number of maternal deaths, which indicated a total of 68 maternal or late maternal deathsvii in Montana between 2006 and 2022.87 Additional maternal and child health data are presented within the Morbidity section of the report. Life expectancy is defined as the average number of years a group of persons are expected to survive from a given starting age (typically at birth).88 Current county-level data on life expectancy were unavailable at the time of this report and instead census-tract data as of 2010-2015 are discussed in addition to state and national comparisons and changes over time. Suicide is among the leading causes of death not only in Gallatin County but also throughout Montana and the United States (Figure 44). The CDC defines suicide as “death caused by injuring oneself with the intent to die” and reports that nationally, suicide rates increased by 36% between 2000 and 2022 and has become a serious public health issue.89 The data related to suicide is reported as an age-adjusted vii A "maternal death" is the death of a female while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accident or incidental causes. Maternal conditions are those assigned to pregnancy, childbirth, and the puerperium (ICD-10 codes A34, 000-095, and 098-099). "Late maternal deaths" are those attributed to the same causes, but which occurred more than 42 days after termination of the pregnancy. The 2003 revision of the Montana death certificate added a pregnancy history item which indicates whether the decedent was pregnant within the 12 months prior to death. This new item makes the identification of a greater number of maternal and late maternal deaths possible. (Public Health and Safety Division, Epidemiology and Scientific Support Bureau, Surveillance and Informatics Section, Montana Department of Public Health and Human Services (MT DPHHS). (2022). Montana vital statistics 2022 annual report. https://dphhs.mt.gov/assets/publichealth/Epidemiology/VSU/2022MTVitalStatisticsFinal.pdf) 62 rate per 100,000 residents and is from the local, state, and national levels. Youth-related suicide indicators are collected via CDC-based behavioral health surveys administered to small samples of middle school (grades 7-8) and high school students. Unintentional injury-related mortality refers to deaths that occur as a result of accidental and external forces. Unintentional injury deaths also are among the leading causes of death within Gallatin County, Montana, and the United States (Figure 44). The CDC reports that between 1981-2022 the leading causes of unintentional injury deaths among Americans aged 1-44 include drug overdoses, motor vehicle accidents, drowning, and falls.90 This report will explore the leading causes of unintentional injury deaths, primarily expanding on data related to overdoses and motor vehicle accidents. Overdose rates over time will be presented in addition to the most commonly associated drug types and differences in subpopulations. Metrics related to motor vehicle accidents include counts over time, associated vehicle types, and the percent of fatalities associated with drunk drivers. Intentional mortality includes deaths that occur as a result of violence, most commonly self-inflicted (suicide) or external (homicide). Mortality rates per 100,000 population related to both suicide and homicide are explored at the county, state, and national levels. WHY WE LOOKED AT IT The metrics informing the mortality data were selected by the Core Group. Mortality data is crucial for informing public health strategies and actions taken toward improving overall community health. WHAT PUBLIC HEALTH KNOWS ABOUT THE IMPORTANCE OF THIS Mortality data are a primary source of information used to identify and monitor the most prevalent conditions (chronic or infectious) with the most severe impact on negative health outcomes in a population. BRIEF NARRATIVE (LINKS TO SOCIAL DETERMINANTS OF HEALTH) Data related to mortality are explored to gauge the most prominent health concerns and to identify and better understand persistent trends that exist within subpopulations. For example, both disability and poverty are historically correlated with increased morbidity and subsequently increased risk of premature death.91 92 FRAMING TOPIC FROM THE LITERATURE The CDC reports that from 2010 to 2022, the percentage of preventable deaths in the United States increased for unintentional injury (including: overdoses, motor vehicle accidents, drowning, falls, stroke) among those less than 80 years old.93 Although not all factors associated with increased morbidity and mortality can be avoided (genetic predisposition), an estimated 50% of disease-related deaths are preventable, including those caused by cancer, chronic respiratory disease, Type 2 diabetes, and cardiovascular disease.94 Exploring and understanding the burden of mortality (especially preventable mortality) allows for informed interventions and opportunities aimed at improving overall health and well-being. 63 LOCAL DATA DISCUSSION Mortality data in this report are derived from secondary sources. Differences between subgroups were evaluated where data were available. As with the data informing the morbidity section of the community assessment, data evaluating the differences in mortality outcomes between subpopulations of Gallatin County residents were difficult to obtain and is overall sparse. LEADING CAUSES OF DEATH Below are the top 10 leading causes of death in Gallatin County between 2018-2022 compared to statewide and national age-adjusted mortality rates. The top causes of death differ slightly between the three geographies; within Montana, Parkinson’s Disease is ranked as the 13th leading cause of mortality and chronic liver disease/cirrhosis is ranked nineth; while nationally, Parkinson’s Disease is ranked as the 15th leading cause of death and nephritis/nephrotic syndrome/nephrosis is 10th. Heart disease remains the top cause of mortality in all three geographic levels and is responsible for an estimated 138 deaths per 100,000 residents in Gallatin County, 167 deaths per 100,000 nationally, and 166 deaths per 100,000 statewide. Cancer (of all sites) is responsible for the second-highest age-adjusted mortality rate, causing approximately 117 deaths per 100,000 residents in the county, 142 deaths per 100,000 throughout Montana, and 146 deaths per 100,000 in the United States. Compared to state and national estimates, Gallatin County has lower age-adjusted mortality rates among each of the leading causes except suicide, Parkinson’s disease, and Alzheimer disease. As of 2022, suicide was associated with approximately 21 deaths per every 100,000 Gallatin County residents, which is about 50% higher than the national rate of 14 deaths per 100,000 residents and 22% lower than statewide estimates of 27 deaths per 100,000. Data regarding Parkinson’s disease indicated all three geographies have similar age-adjusted mortality rates of about nine deaths per 100,000 residents. The age-adjusted mortality rate for Alzheimer disease within Gallatin County is about 23% higher than statewide estimates (30 per 100,000 and 23 per 100,000, respectively), and is comparable to national estimates with only a 3% difference. Supplemental data provided (see Appendix1) highlighted differences in the leading causes of death among various age groups and races/ethnicities throughout the county (Tables 3 and 4). Between 2012 and 2023, heart disease was the leading cause of death among all races as well as the White, non- Hispanic population in Gallatin County. However, among the American Indian/Alaska Native and Hispanic populations, malignant neoplasms (cancers) were the leading causes of death, while accidents caused the most deaths among the Black, non-Hispanic population and suicide caused the most deaths among the Asian/Pacific Islander population in the county. When evaluating differences in mortality by age groups during the same 12-year period, heart disease was found to cause the highest number of deaths among all age groups and those while malignant neoplasms were the leading cause among 45– 64-year-olds in the county. But within the younger age groups, accidents caused the greatest number of deaths among 1-14 year-olds and 25-44 year olds while suicide cause the most number of deaths among 15-24 year olds between 2012-2023. 64 In order to measure premature mortality (early death), public health researchers calculate the years of potential life lost before the age of 75. Within Gallatin County, unintentional injuries are responsible for the highest level of years of potential life lost, with an estimated 4,800 years lost between 2018-2022. According to the CDC, unintentional injuries are the leading cause of mortality among Americans aged 1- 44 years old.95 The most common unintentional injuries resulting in death include unintentional poisoning (such as drug overdoses), unintentional motor vehicle traffic, unintentional drowning, and unintentional falls.96 In Gallatin County, cancer (of all sites), suicides, and heart disease also account for some of the most common reasons of years of potential life lost. During the five-year period, an estimated 4,072 years were lost due to cancers, 4,044 years were lost due to suicides, and 2,900 years were lost due to heart disease. 0 20 40 60 80 100 120 140 160 180 Heartdisease Cancer Unintentional injury Alzheimer Disease Cerebrovasculardiseases Chronic lower respiratory disease COVID-19 Suicide Parkinson's Disease Diabetes Mellitus Age-adjusted mortality rate per 100,000Cause of deathFigure 44: Leading Causes of Mortality with Age-adjusted Rates per 100,000 Population in Gallatin County, MT, Statewide, and the United States in 2018-2022 Gallatin County Montana United States Sources: Montana Department of Public Health and Human Services, Vital Statistics Analysis Unit & CDC, National Center for Health Statistics 65 Cardiovascular disease, also known as heart disease, is the leading cause of death at the local, state, and national levels according to 2022 estimates (Figure 44). According to 2021 data from the CDC, Gallatin County’s age-adjusted cardiovascular disease mortality rate was approximately 316 deaths per every 100,000 residents. Overall, this rate is lower than state and national levels (404 per 100,000 and 432 per 100,000, respectively). When evaluating county-level data regarding race and ethnicity, data were unavailable for the Black, American Indian/Alaska Native, Asian, and Native Hawaiian or Other Pacific Islander populations as well as individuals of more than one race. The available data indicate that the White (non-Hispanic) population had a higher cardiovascular disease mortality rate than the Hispanic population (320 per 100,000 and 207 per 100,000, respectively). The CDC also has available data on age- adjusted cardiovascular disease mortality rate disparities between sexes, indicating that 366 per 100,000 males compared to 274 per 100,000 females die due to cardiovascular disease in Gallatin County. 4,800 4,072 4,044 2,900 601 373 318 253 90 220 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500 5,000 UnintentionalinjuryCancerSuicideHeartdiseaseCOVID-19Chronic lowerrespiratory diseaseDiabetesMellitusCerebrovasculardiseasesAlzheimerDiseaseParkinson'sDiseaseYears of potential life lost before age 75Cause of death Figure 45: Years of Potential Life Lost before Age 75 for Leading Causes of Mortality in Gallatin County, MT in 2018-2022 Source: Montana Department of Public Health and Human Services, Vital Statistics Analysis Unit 66 INFANT MORTALITY The CDC recognizes infant mortality (or the death of an infant <1 year old) as an important indicator for the overall health of a society.97 Compared to statewide and national data, Gallatin County had a lower infant mortality rate. An estimated 3.3 infants per 1,000 live births died between 2013 and 2022 within the county, compared to 5.3 deaths per 1,000 live births within Montana, and 5.6 deaths per 1,000 live births across the United States. 316 404 432 164 50 1,129 274 366 207 320 0 200 400 600 800 1,000 1,200 Gallatin CountyMontanaUnited StatesAll ages35-64 years65+ yearsFemalesMalesHispanicWhite, non-HispanicLocation Age Sex Race and ethnicityAge-adjusted rate per 100,000Figure 46: Age-adjusted Cardiovascular Disease Mortality Rate per 100,000 Population by Race/Ethnicity, Gender, and Location, Gallatin County, MT in 2019- 2021 Data Source:National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention 67 County-level maternal mortality data is unavailable due to low annual incidence. Across the state of Montana, data from 2006 to 2022 indicated an increase in the number of annual maternal and late maternal deaths. A total of nine maternal or late maternal deaths occurred among Montana residents in 2022, an approximate 350% increase from the two deaths reported in 2006. These estimates do not factor in changes to Montana's population over time, therefore true rates are unknown. As of 2021, the birth rate at the county and state levels were both estimated to be approximately 10.2 births per 1,000; this is slightly lower than the nationwide birth rate of 11.0 in the same year. Compared 5.6 5.3 3.3 0 1 2 3 4 5 6 United States Montana Gallatin County Mortality rate per 1,000 live birthsLocationFigure 47: Infant Mortality Rate per 1,000 Live Births in Gallatin County, MT, Statewide, and the United States in 2013-2022 Sources: Montana Department of Public Health and Human Services, Vital Statistics Analysis Unit and CDC, National Center for Health Statistics 0 1 2 3 4 5 6 7 8 9 10 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022Number of deathsYear Figure 48: Annual Maternal and Late Maternal Deaths in Montana from 2006- 2022 Sources: Montana Department of Public Health and Human Services, Vital Statistics Unit 68 to 2016, the birth rate has dropped by about 15% in Gallatin County and Montana residents; within the United States, the birth rate dropped about 10% during the same six-year period. LIFE EXPECTANCY (NARRATIVE) Current county-level data regarding life expectancy was not available at the time of this report. The CDC instead reports life expectancy at the census-tract level, indicating an average of 80.9 years (range: 74.4- 87.3) among the 19 of 22 Gallatin County census tracts with large enough sample sizes in 2010-2015.98 State-level data from 2020 shows that the life expectancy among Montanans was about 76.8 years, down slightly from 78.7 years in 2018. Compared to the rest of the country, life expectancy in Montana was higher than about 49% of other states in the United States as of 2020.99 The most up-to-date life expectancy information is available at the national level and indicates that as of 2022, life expectancy at birth was approximately 77.5 years at birth among the total U.S. population representing an increase of 1.1 years from 2021. Life expectancy also varies between sexes; in 2022 life expectancy was 73.5 years among males and 79.3 among females, both of which increased 1.3 and 0.9 years from 2021, respectively.100 SUICIDE Suicide is a leading cause of death across all age groups throughout the United States.101 Gallatin County and the state of Montana trend higher than the United States according to data between 2016 and 2022. An estimated 25 per 100,000 Gallatin County residents died by suicide in 2022, representing a 9% increase from the local suicide rate in 2016 (23 per 100,000). Statewide, suicide rates exceeded local estimates; in 2022 approximately 30 per 100,000 Montanans died by suicide, a 15% increase from the 0 2 4 6 8 10 12 14 2016 2017 2018 2019 2020 2021Birth rate per 1,000Year Figure 49: Birth Rate per 1,000 Population in Gallatin County, MT, Statewide, and the United States from 2016 to 2021 Gallatin County Montana United States Sources: Montana Department of Public Health and Human Services, Vital Statistics Report & CDC, National Center for Health Statistics 69 rate of 26 per 100,000 in 2016. Across the United States, suicide rates which have also been increasing over time, however, remain overall lower than both the local and statewide estimates. In 2022, 14 per 100,000 U.S. residents died by suicide, representing an 8% increase from the suicide rate in 2016 (13 per 100,000). Below (Figures 51 and 52) are behavioral risk factor survey-based data from surveyed high school and middle school (grades 7-8) students in Gallatin County between 2017 and 2023. Each figure pertains to a different school level but contains the same suicide-related survey questions. Both datasets indicate overall worsening mental health indicators among surveyed students over the seven-year period. According to the self-reported data among surveyed high school students (Figure 51), each of the four suicide indicators have worsened slightly between 2017 and 2023. The most notable change among the high schoolers over the seven-year period is that 4% more students reported attempting suicide in the past year and 3% more students reported seriously considering suicide in the past year. Among middle school students (Figure 52), three of the four suicide indicators worsened while the fourth remained steady between 2017 and 2023. The percent of middle schoolers reporting that they had seriously considered suicide in the past year increased by 6% and the percent of students who made a plan about how they would attempt suicide in the past year increased by about 3%. The percent of middle schoolers reporting they attempted suicide which resulted in necessary medical intervention increased by 1%. The overall percent of students reporting having attempted suicide at least once in the last year remained steady at 12% from 2017 to 2023. 0 5 10 15 20 25 30 35 2016 2017 2018 2019 2020 2021 2022Age-adjusted rate per 100,000Year Figure 50: Age-adjusted Suicide Rate per 100,000 Population in Gallatin County, MT, Statewide, and the United States from 2016 to 2022 Gallatin County Montana United States Sources: Montana Department of Public Health and Human Services, Vital Statistics Report and CDC, National Center for Health Statistics 70 21% 15% 14% 4% 21% 16% 14% 3% 25% 22% 14% 5% 18% 15% 10% 2% 0%5%10%15%20%25%30% I seriously considered attempting suicide in the past 12 months I made a plan about how I would attempt suicide inthe past 12 months I have attempted suicide at least once in the past 12 months I attempted suicide that resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse Percent Figure 51: Suicide Indicators among Surveyed High School Students in Gallatin County, MT from 2017 to 2023 2017 2019 2021 2023 Source: Youth Risk Behavior Survey,Centers for Disease Control and Prevention 19% 16% 12% 4% 17% 16% 10% 3% 16% 17% 16% 4% 13% 13% 12% 3% 0%5%10%15%20%25% I seriously considered attempting suicide in the past 12 months I made a plan about how I would attempt suicide in the past 12 months I have attempted suicide at least once in the past 12 months I attempted suicide that resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse Percent Figure 52: Suicide Indicators among Surveyed Middle School Students in Gallatin County, MT, from 2017 to 2023 2017 2019 2021 2023 Source: Youth Risk Behavior Survey,Centers for Disease Control and Prevention 71 INTENTIONAL AND UNINTENTIONAL INJURY-RELATED MORTALITY As previously mentioned, the CDC reports that unintentional injuries are the leading cause of mortality among Americans aged 1-44 years old.102 According to data from 2018-2022, the most prevalent cause of unintentional injury death in Gallatin County was accidental falls with an estimated 11 per 100,000 fatalities. Gallatin County’s fall-related mortality rate is comparable to national estimates and is lower than statewide rates (15 per 100,000). Motor vehicle accidents represented approximately 10 deaths per 100,000 residents in the county, slightly lower than state and nationwide mortality rates (19 per 100,000 and 12 per 100,000, respectively). The “other” causes of unintentional injury deaths (accidental discharge of firearms, drowning, exposure to smoke/fire/flames, and unspecified non-transport-related deaths) account for approximately 9 deaths per 100,000 residents in the county, which is lower than Montana’s statewide rate of 12 per 100,000 but much higher than the national mortality rate of 2 per 100,000. Across the United States, most (29 per 100,000) unintentional injury deaths are attributable to accidental poisoning or exposure to a noxious substance; these estimates also include unintentional drug overdose fatalities such as those related to opioids, alcohol, or other drugs. Comparatively, Gallatin County and the state of Montana both have much lower mortality rates associated with accidental poisonings (7 per 100,000 and 15 per 100,000, respectively). Overall, Gallatin County has lower age-adjusted unintentional injury-related mortality rates across all causes compared to the state of Montana and lower mortality rates associated with motor vehicle accidents and accidental poisonings than the United States. Prior to 2023, the CDC reported that fatal drug overdoses had been on the rise across the country since 2018; noting that overdose deaths involving specifically synthetic opioids (primarily fentanyl) also 11 12 2 29 15 19 12 15 11 10 9 7 0 5 10 15 20 25 30 35 Accidental Fall Motor Vehicle Accident Other* Accidental Poisoningor Exposureto Noxious… Age-adjusted mortality rate per 100,000 person-years Figure 53: Unintentional Injury Mortality Rates per 100,000 Population in Gallatin County, MT, Statewide, and the United States in 2018-2022 Gallatin County Montana United States Sources: Montana Department of Public Health and Human Services, Vital Statistics Analysis Unit & Centers for Disease Control & Prevention, National Center for Health Statistics // 72 decreased in 2023, but deaths associated with cocaine and psychostimulants (like methamphetamine) increased.103 The available local data from 2003 to 2021 follows a similar trend within Gallatin County, indicating an approximate 267% increase in the crude substance use mortality rate over the 19-year period. Drug overdoses have severe and life-threating impacts and are one of the leading causes of injury- related mortality in U.S. adults.104 Local data collected between 2009 to 2023 indicated that there are differences in the number of fatal drug overdoses between age groups and sexes. Over the 15-year period, males in Gallatin County experienced more fatal drug overdoses than females, and there were more fatal overdoses among adults ages 25 to 44 years compared to younger or older adults. Data related to race and ethnicity was not available at the county level, however, statewide data estimated that the age-adjusted overdose fatality rate is highest among American Indians/Alaska Natives. From 2009-2023, approximately 33.5 per 100,000 American Indians/Alaska Natives in Montana died due to alcohol compared to 21.5 per 100,000 Black residents and 12.8 per 100,000 White residents.105 0 2 4 6 8 10 12 14 16 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021Mortality rate per 100,000Year Figure 54: Crude Drug Overdose Death Rate per 100,000 Population in Gallatin County, MT from 2003 to 2021 Source: National Center for Health Statistics, Centers for Disease Control and Prevention 73 Among the fatal drug overdosesviii in Gallatin County between 2009 and 2023, most (64%) are associated with alcohol use and an estimated 16% are associated with general opioid use. Compared to the rest of the United States, Montana has the second highest percentage of adults who report binge drinking during the past 30 days, estimated to be about 24% as of 2022.106 Nationally, an estimated 17% of adults report binge drinking and the CDC estimates a 29.3% increase in the average number of alcohol-related deaths from 2016-2017 to 2020-2021.107 Similar increasing trends can be observed with opioid-related mortality rates over time. Opioids are a group of drugs typically prescribed by physicians for pain management (e.g., Hydrocodone, Oxycodone, Morphine), but can also be synthetically manufactured (such as illegally made fentanyl). Due to their highly addictive nature, misuse or abuse of either prescription and synthetic opioids can lead to drug dependency and potential overdose. As previously stated, the CDC reports that although national opioid deaths are decreasing for the first time since 2018, overdose deaths associated with psychostimulants (e.g., cocaine, methamphetamine) increased as of 2022 data.108 Locally, psychostimulants are responsible for approximately 5% of fatal overdoses between 2009 and 2023. The least common drug viii All fatal overdoses include any death records listing an underlying cause ICD-10 code of X40-X44, X60-X64, X85, Y10-Y14. Opioid-related deaths include records listing underlying cause codes in any field: T40.0, T40.1, T40.2, T40.3, T40.4, or T40.6. Overdose deaths due to Fentanyl are not captured using ICD-10 Codes because there is currently no specific ICD-10 code for fentanyl. Fentanyl deaths are captured by searching text literals on the death certificate. Fentanyl is a synthetic opioid so it should be coded as T40.4, but there is no way to specifically identify fentanyl if the term is not mentioned in literal text. Simulant-related deaths include records listing underlying cause codes in any field: T40.5 or T43.6. Heroin-related deaths include records listing underlying cause codes in any field: T40.1. Alcohol-related deaths include records listing underlying cause codes in any field: F10.3-F10.9, F10.0, F10.1, F10.2, G62.1, G31.2, G72.1, I42.6, K29.2, K70.0-K70,4, K70.9, K85.2, K86.0, Q86.0, P04.3, X45, Y15, X65, O35.4, or T51.0. (Montana EMS, Trauma Systems and Injury Prevention Program, Montana Department of Public Health and Human Services. Retrieved from https://dphhs.mt.gov/assets/publichealth/EMSTS/Data/MTInjuryIndicators.pdf) 0 11 67 38 8 91 36 0 10 20 30 40 50 60 70 80 90 100 0-19 years 20-24 years 25-44 years 45-64 years 65+ years Male Female Age Group SexNumber of overdosesFigure 55: Number of Fatal Drug Overdoses by Age Group and Sex in Gallatin County, MT in 2009-2023 Source: EMS, Trauma Systems, & Injury Prevntion Program, Montana Department of Public Health and Human Services 74 associated with fatal overdoses in the county is heroin, estimated to cause about 3% of the overdose fatalities in the 15-year period. Motor vehicle accidents are among the leading causes of death, responsible for causing about 110 deaths per day across the United States.109 Below (Figures 57 and 58) are county-level data from the National Highway Traffic Safety Administration collected between 2003 and 2022, indicating that within Gallatin County, the number of traffic-related fatalities has decreased by 60% over the 20-year period. Most of the vehicle-related fatalities in the county were associated with light trucks (49%) or passenger cars (35%). In comparison, motorcycles accounted for approximately 10% of vehicle-related fatalities and less than 5% were attributed to large trucks. 16% 3% 6% 6% 5%64% Figure 56: Percent of Fatal Overdoses by Drug Type in Gallatin County, MT in 2009- 2023 Opioids, other Heroin Synthetic opioids Fentanyl Stimulants Alcohol Source: EMS, Trauma Systems, & Injury Prevntion Program, Montana Department of Public Health and Human Services 0 5 10 15 20 25 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022Number of fatalitiesYear Figure 57: Annual Number of Vehicle-related Fatalities in Gallatin County, MT from 2003 to 2022 Source: National Highway Traffic SafetyAdministration, United States Department of Transportation 75 Additional data from the National Highway Traffic Safety Administration indicated that between 2003 and 2022, alcohol-impaired drivers accounted for 30% of all traffic-related deaths. During the same 20- year period, both local and state-wide alcohol-related traffic mortality rates exceeded national estimates; with about 36% of fatal traffic accidents within Gallatin County and 39% of fatal traffic accidents within Montana attributed to alcohol-impaired drivers. The highest percentage of alcohol- impaired traffic fatalities in Gallatin County was observed in 2017-2018 at about 72%. Intentional injury-related mortality refers to either death as a result of self-harm (suicide) or death as a result of another person (homicide). Within Gallatin County, homicide rates are suppressed due to <20 total events between 2018 and 2022. However, data from the Montana Incident-Based Reporting System indicated that among the other three Montana counties with similar population sizes 35% 49% 2%4% 10% Figure 58: Percent of Vehicle-related Fatalities by Vehicle Type* in Gallatin County, MT in 2003-2022 Passenger car Light truck Large truck Other/unknown Motorcycle Source: National Highway Traffic SafetyAdministration, United States Department of Transportation *Buses are also included in the count, however no bus-related fatalities occured in Gallatin County during 2003-2022 0% 10% 20% 30% 40% 50% 60% 70% 80% 2003-2004 2005-2006 2007-2008 2009-2010 2011-2012 2013-2014 2015-2016 2017-2018 2019-2020 2021-2022Percent of vehicle fatalitiesYear Figure 59: Percent of Vehicle Fatalities with Driver Blood Alcohol Content Greater Than or Equal to 0.08 in Gallatin County, MT, Statewide, and the United States from 2003 to 2022 Gallatin County Montana United States Source: National Highway Traffic Safety Administration (NHTSA) 76 (Yellowstone, Missoula, and Flathead Counties), Gallatin County had the lowest criminal offense rate per 100,000 residents between 2018 and 2022.110 Homicide levels among the nation were slightly higher than those statewide (7 deaths per 100,000 and 5 deaths per 100,000, respectively). Mortality due to suicide was highest throughout the state, with an estimated 17 deaths per 100,000 residents attributed to suicide by firearm and 10 deaths per 100,000 residents attributed to suicide by another mechanism. Comparatively, rates in Gallatin County are similar among suicides due to firearms (15 per 100,000), but about half as many suicides are due to other mechanisms compared to statewide estimates. Nationally, the mortality rate per 100,000 is similar among all three indicators with an estimated seven deaths per 100,000 attributed to each cause of death. HEALTH FACTORS Health factors refer to a broad set of characteristics or variables which influence an individual’s overall health status. Some health factors are beyond individual influence and require societal changes at the infrastructure or policy level, while other factors can be improved through individual behavioral changes. DISCUSSION OF THE FOUR HEALTH FACTORS COMPONENTS AND HOW THEY ARE CONNECTED Within health factors, four major components of health were selected based on the county health rankings model,111 and were evaluated through county level population health indicators. The four sections consist of data which explore health behaviors, access to services, social and economic factors, and environmental factors in Gallatin County, and how each impacts residents’ overall health. Though separate indicators are used to capture each of the four sections, they are all deeply intertwined in how they relate to community health. For example, low socioeconomic status has been associated with limited access to resources (e.g., stable housing, healthy foods, safe neighborhoods) which are needed to support a healthy quality of life.112 15 5 17 10 5 7 7 7 0 2 4 6 8 10 12 14 16 18 20 Suicide by firearm Suicide by other mechanism Homicide†Age-adjusted rate per 100,000Cause of death Figure 60: Intentional Injury Mortality Rate per 100,000 Population in Gallatin County, MT, Statewide, and the United States in 2018-2022 Gallatin County Montana United States Sources: Montana Department of Public Health and Human Services, Vital Statistics Analysis Unit and CDC, National Center for Health Statistics†County-levelhomicide data are suppressed 77 DISCUSSION OF IMPACTS OF HEALTH FACTORS ON HEALTH OUTCOMES Health factors related to the environment, access, socioeconomics, and behavior are highly influential in nearly all aspects of health. Residents living in areas with reduced access to goods and services are subsequently at increased risk of developing chronic conditions, mental health issues, experiencing higher mortality, and lower life expectancy.113 Therefore, it is crucial that populations have equitable access to the goods and services which support healthy lifestyles and options. In addition to access, individuals need to practice healthy behaviors while minimizing the riskier behaviors which negatively impact health. For example, engaging in healthy behaviors, such as eating healthfully and being active, can reduce the risk of chronic diseases which then lowers the morbidity and mortality rates.114 Conversely, unhealthy behaviors, such as poor nutrition, physical inactivity, or substance abuse, are linked to higher rates of chronic conditions and contribute to increased morbidity and mortality.115 116 DISCUSSION OF IMPACTS OF COMMUNITY PROFILE ON HEALTH FACTORS Healthy behavior and access to healthcare services are highly influenced by differences associated with various non-medical factors, like age, race/ethnicity, or income. Age plays a key role in morbidity and mortality disparities, with most older adults in the United States diagnosed with at least one chronic health condition.117 It is also vital to consider factors like race and ethnicity when evaluating differences in morbidity and mortality outcomes, as the CDC reports that across the country, minority populations experience higher rates of poor health and disease compared to White populations.118 Additional community context, like population growth, income, and housing also are crucial to consider when evaluating population health because they can potentially frame why certain disparities exist or have shifted over time. For example, a 2024 study by the CDC found that in comparison to homeowners, renters are at significantly higher odds of developing several chronic conditions, like diabetes, stroke, and kidney disease.119 Throughout the report, several indicators highlight housing struggles among Gallatin County residents, so understanding this context and if/how it may relate to the morbidity and mortality data is critical in assessing community health. HEALTH BEHAVIORS Health behaviors are health-related practices, such as diet and exercise, that can improve or damage the health of individuals or community members. Health behaviors are determined by the choices available in the places where people live, learn, work, and play. WHAT IS THE PURPOSE OF THIS TOPIC AND WHAT DO WE WANT TO KNOW? It is important to explore health behaviors as part of the community health assessment to gain a comprehensive understanding of what health-related practices are being utilized by the community. BRIEF INTRODUCTION OF METRICS This community health assessment explored health behaviors related to community interactions, substance use, healthy eating, how individuals understand health behaviors, and physical activity in Gallatin County. 78 WHAT DID WE LOOK AT? Community interaction is the interplay of influences that enable or prevent individuals and families in a community to interact in positive and supportive ways across the lifespan. These influences are related to social relationships and connection, place-based factors, and individual habits and skills. In exploring community interaction within Gallatin County, indicators such as excessive screen time, youth social media use, social isolation among older adults, and instances of bullying were examined to gain insights into the community's interactions. Substance use is the use of illegal drugs and inappropriate use of legal substances, (e.g., alcohol and tobacco) that can lead to possible dependence and other negative health outcomes.120 In exploring substance use within Gallatin County, indicators such as youth substance use, overdose hospitalizations, tobacco use, and alcohol use were examined to gain insights into the community's substance use behaviors. Healthy eating is the practice of consuming a variety of nutritionally balanced food and drinks in recommended amounts and distributions. Healthy eating is impacted by the availability, cost, quality of food in an area, and a variety of other community and individual factors.121 In exploring healthy eating within Gallatin County, indicators such as youth behaviors and food insecurity were examined to gain insights into the community's healthy eating behaviors. Understanding health behaviors focuses on how individuals interpret and make meaning from health- related information. By understanding how behavior influences health, individuals have more autonomy to impact their own health. The quality of that information can have unintended future consequences on an individual’s health behaviors. Unfortunately, there were no existing data available for Gallatin County regarding how the community understands health behaviors. Instead, indicators were included in this assessment focused on individual behaviors such as concussions, sleep, and sexual activity among youth to gain insights into the community's understanding of health behaviors. Physical activity is moving one’s body by exerting physical effort in line with recommended duration and movement type. Physical activity is done over the lifespan, and is impacted by seasons, access to safe spaces, and knowledge of recommendations, benefits, and applications. In exploring physical activity within Gallatin County, indicators such as adult and youth participation in exercise, were examined to gain insights into the community's physical activity behaviors. WHY WE LOOKED AT IT These topics were selected by the Community Committee. The committee selected these factors because they have a strong influence on the health of Gallatin County and because the community believes they have the ability to impact these factors. WHAT PUBLIC HEALTH KNOWS ABOUT THE IMPORTANCE OF THIS It is well established that many different individual health behaviors can influence individual and community health outcomes.122 123 124 79 FRAMING TOPIC FROM THE LITERATURE Research has indicated that between 25 to 40% of the modifiable factors influencing health stem from health-related behaviors.125 126 127 BRIEF NARRATIVE (LINKS TO SOCIAL DETERMINANTS OF HEALTH) While the factors in this section of the assessment focus on the behavior of individuals, it is critical to acknowledge that all individual’s choices are strongly influenced by the conditions in which they live, learn, work, and play. Many individuals do not have the resources, access, time, or privilege that is needed to make healthy choices. Others live in places that make it very difficult to make healthy choices. Sometimes, it is difficult to make healthy choices because of factors outside of an individuals’ control, such as addiction. Addressing these systemic barriers is essential to promoting equitable access to health-promoting behaviors for all individuals. LOCAL DATA DISCUSSION This community health assessment explored existing data from Gallatin County, looking at differences between subgroups and geographic areas when that information was available. COMMUNITY INTERACTIONS According to the 19th and 21st Surgeon General of the United States, Dr. Vivek H. Murthy, a lack of social connections or community interactions can pose a significant risk for individual health and longevity.128 It is associated with an increased risk of heart disease, stroke, anxiety, depression, dementia, and an increased susceptibility to viruses and respiratory illnesses.129 130 131 132 133 In Gallatin County, 4% of adults aged 65 and older reported living alone between 2018 and 2022, which is lower than Montana and the United States. 3% 6% 5% 4% 7% 6% 0% 1% 2% 3% 4% 5% 6% 7% 8% Gallatin County Montana United StatesPercent of adults aged 65+Location Figure 61: Percent of Adults Aged 65+ Living Alone in Gallatin County, MT, Statewide, and the United States from 2013 to 2022 2013-2017 2018-2022 Source: United States Census Bureau, American Community Survey 5-year estimates 80 In 2024, community members who participated in local focus groups reported experiencing social isolation. They attributed this to a lack of close friends or family in the area, which is influenced by housing availability and affordability. Additionally, the high cost of living was identified as a barrier to socializing and forming meaningful connections. The CDC defines bullying as “any unwanted aggressive behavior(s) by another youth or group of youths, who are not siblings or current dating partners, that involves an observed or perceived power imbalance, and is repeated multiple times or is highly likely to be repeated.” 134 Bullying can result in physical injury, social and emotional distress, self-harm, and even death.135 Twenty-three percent of high school students and 35% of middle school students locally reported having been bullied on school property in the 12 months. Almost 1 in 5 students reported having been teased or called names because someone thought they were gay, lesbian, or bisexual, and almost 1 in 5 reported having been bullied electronically in the last 12 months. Data about community interactions was not available at the demographic and geographic subgroup levels for Gallatin County, though national research shows that adolescent females are more likely to be bullied electronically136 and high school students who identify as lesbian, gay, or bisexual are almost twice as likely to be bullied as those who identify as heterosexual.137 Excessive screen-time exposure has been linked to poor health outcomes ranging from weight gain, physical inactivity, reduced sleep quality, poor body image perception, poor nutrition, and mental health conditions such as anxiety and depression.138 Sixty-seven percent of high school students and 56% of middle school students reported spending three or more hours per day on screen time, excluding schoolwork. This has not changed since 2021. 29% 21% 17%16% 12%10% 35% 19%18%17% 20% 13% 25% 14% 18%16%16%16% 35% 23%21% 16% 19%17% 0% 5% 10% 15% 20% 25% 30% 35% 40% Middle School High School Middle School High School Middle School High School I have been bullied on school property inthe past 12 months I have been bullied electronically duringthe past 12 months I have been teased or called namesbecause someone thought I was gay,lesbian, or bisexual in the past 12 monthsPercent of surveyed studentsFigure 62: Percent of Surveyed Students Reporting Being Bullied/Teased in Gallatin County, MT from 2017 to 2023 2017 2019 2021 2023 Source: Youth Risk Behavior Survey, Centers for Disease Control and Prevention 81 Youth social media use can have a negative impact on youth mental health, including an increased risk of anxiety, depression, negative body image and disordered eating behaviors, as well as poor sleep quality.139 Seventy-nine percent of high school students and 61% of middle school students reported using social media at least once per day. Thirty-four percent of high school students and 25% of middle school students reported using social media at least hourly. 59% 68% 56% 67% 0% 10% 20% 30% 40% 50% 60% 70% 80% Middle School High SchoolPercent of studentsSchool type Figure 63: Percent of Surveyed Students Spending 3+ Hours per Day on Screen Time (excluding Schoolwork) in Gallatin County, MT in 2021 and 2023 2021 2023 Source: Youth Risk Behavior Survey, Centers for Disease Control and PreventionData prior to 2021 is unavailable due to question not being included in survey 10% 27% 6% 19% 8% 38% 10% 24% 0% 5% 10% 15% 20% 25% 30% 35% 40% About once a day Several times a day About once an hour More than once an hourPercent of surveyed studentsSurvey response Figure 64: Percent of Surveyed Students Using Social Media at Least Daily in Gallatin County, MT in 2023 Middle School High School Source:Youth Risk Behavior Survey, Centers for Disease Control and Prevention Data prior to 2023 is unavailable due to question not being included in survey 82 SUBSTANCE USE The use of illegal drugs and inappropriate use of legal substances can negatively impact health. Youth substance use can impact brain development and increase the risk of developing substance use disorder as an adult.140 In Gallatin County, 51% of high school students and 28% of middle school students reported having consumed more than a few sips of alcohol in 2023. Thirty-four percent of high school students have used an electronic vapor product in 2023, which was a decrease from 43% in 2017. Almost 1 in 4 high school students and 1 in 5 middle school students have been offered, sold, or given illegal drugs on school property in the past year. In 2023, 12% of middle and high school students reported taking a prescription pain medicine without a doctor’s prescription or differently than how the doctor instructed to use it. Twenty-nine percent of high school students and 9% of middle school students have tried marijuana. 12% 17% 28% 9% 12% 18% 11% 17% 26% 8% 11% 16% 13% 21% 28% 11% 10% 18% 11% 13% 25% 7% 7% 17% 0%5%10%15%20%25%30% I have tried cigarette smoking - even one or two puffs I have used an electronic vapor product I have consumed more than a few sips of alcohol I have tried marijuana I have taken perscription pain medicine without a doctor's perscription, or differently than how the doctor instructed to use it I have been offered, sold, or given illegal drugs on school propety in the past year Percent of surveyed studentsSubstance use indicatorFigure 65: Percent of Surveyed Middle School Students Indicating Substance Use in Gallatin County, MT from 2017 to 2023 2017 2019 2021 2023 Source: Youth Risk Behavior Survey, Centers for Disease Control and Prevention 83 There are differences in the number of non-fatal drug overdoses between different age groups and sexes, though these differences do not consider the differences in demographic groups. Females experienced more non-fatal drug overdose hospitalizations than males, and younger adults experienced more non-fatal overdose hospitalizations than older adults. 19% 34% 51% 29% 12% 23% 22% 40% 56% 29% 10% 21% 27% 51% 61% 35% 13% 27% 25% 43% 58% 34% 14% 19% 0%20%40%60%80% I have tried cigarette smoking - even one or two puffs I have used an electronic vapor product I have consumed more than a few sips of alcohol I have tried marijuana I have taken perscription pain medicine without a doctor's perscription, or differently than how the doctor instructed to use it I have been offered, sold, or given illegal drugs on school propety inthe past year Percent of surveyed studentsSubstance use indicatorFigure 66: Percent of Surveyed High School Students Indicating Substance Use in Gallatin County, MT from 2017 to 2023 2017 2019 2021 2023 Source: Youth Risk Behavior Survey, Centers for Disease Control and Prevention 233 203 285 103 86 377 533 87 51 104 58 57 124 233 0 100 200 300 400 500 600 0-17 years 18-24 years 25-44 years 45-64 years 65+ years Male Female Age Group SexNumber of overdosesFigure 67: Number of Non-fatal Drug Overdoses Resulting in Hospitalization by Visit Type, Age Group, and Sex in Gallatin County, MT in 2017-2022 Non-fatal Emergency room visits Non-fatal Hospitalizations Source: EMS, Trauma Systems, & Injury Prevntion Program, Montana Department of Public Health and Human Services 84 Below (Figure 68) are county-level data reporting the number of illegal drug seizures from the Montana Board of Crime Control. The data solely describes counts and does not factor in quantities of seized drugs. Both charts exclude illegal marijuana seizures, as marijuana became recreationally legal in Montana as of 2022. Between 2014 and 2023 there were 2,181 drug seizures in Gallatin County, most (58%) of which involved methamphetamine or other stimulants. These proportions also reflected statewide trends where an estimated 60% of drug seizures involved methamphetamine or other stimulants during the 10-year period.141 The peak number of drug seizures in the county occurred in 2022 where an estimated 278 seizures took place, representing a 6% increase from the number of seizures in 2021 and a 93% increase since 2014. Overall, the number of illegal drug seizures in Gallatin County has increased by 89% over the 10-year period. The most notable increases include the number of unknown drug seizures rising by 700%, cocaine/crack seizures rising by 280%, and methamphetamine/stimulant seizures rising by 136% between 2014 and 2023. Unknown or “other” drug types were associated with about 28% of seizures in the county and the remaining 14% of seizures were related to cocaine/crack or heroine/opioids. Over the 10-year period, Gallatin County accounted for approximately 26% of all cocaine/crack seizures throughout the state of Montana. 0 20 40 60 80 100 120 140 160 180 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023Number of seizuresYear Figure 68: Number of Drug Seizures by Year and Type in Gallatin County, MT from 2014 to 2023 Unknown drug type Cocaine/crack Heroin/opioids Other drugs Methamphetamine/stimulants Source: Montana Board of Crime Control,State of Montana 85 Commercial tobacco use impacts health through increased risk for coronary heart disease, stroke, various cancers throughout the body, addiction, and impaired brain development in youth.142 143 144 Nicotine use impacts health by negatively affecting brain development, and exposure to harmful toxins such as cancer-causing chemicals, volatile organic compounds, and heavy metals.145 Ten percent of adults in Gallatin, Madison, and Park Counties reported smoking tobacco in 2020 and 2021 and 7% reported using smokeless tobacco products such as chewing tobacco, snuffs, and snus. The percent of adults who reported smoking tobacco decreased slightly from 13% in 2016 to 2017 to 10% in 2020 to 2021. 6% 8% 58% 24% 4% Figure 69: Drug Seizures by Type* in Gallatin County, MT in 2014-2023 Cocaine/crack Heroin/opioids Methamphetamine/sti mulants Other drugs Unknown drug type Source: Montana Board of Crime Control, State of Montana*Excluding marijuana, which became recreationally legal in the state of Montana as of 2022 13% 11%10% 6%6% 7% 0% 2% 4% 6% 8% 10% 12% 14% 2016-2017 2018-2019 2020-2021Percent of adultsYear Figure 70: Percent of Adults Who Are Current Smokers or Smokeless Tobacco Users in Gallatin, Madison, and Park Counties, MT from 2016 to 2021 Tobacco Smokeless tobacco* (chewing tobacco, snuff, snus) Source: Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention *Excludes E-Cigarettes 86 Binge drinking, which is defined as having 4 or 5 drinks in a single occasion for women and men, respectively, can have both short and long-term health effects.146 Short-term health effects of binge drinking include an increased risk from injuries (such as motor vehicle crashes, falls, drowning, and burns), violence, alcohol poison, behaviors that can result in unintended pregnancy and sexually transmitted infections, miscarriages, and birth defects.147 Long-term health effects of binge drinking include an increased risk of heart and liver disease, cancer, dementia, depression, anxiety, and a weakened immune system.148 Twenty-two percent of adults reported binge drinking in 2020 and 2021, which was a 50% increase from 2018 and 2019. Data about substance use was not available at the demographic and geographic subgroup levels for Gallatin County, though national research shows that illicit drug use among people aged 12 or older was highest for people reporting two or more races and for American Indian and Alaska Native people compared with all other racial and ethnic groups.149 Nationally, alcohol use was highest for White people compared to all other racial and ethnic groups.150 National estimates for alcohol use disorder, illicit drug use disorder, and past year substance use disorder were highest for American Indian and Alaska Native people compared with all other racial and ethnic groups.151 HEALTHY EATING Eating healthy in alignment with the current U.S. Dietary Guidelines can help individuals achieve and maintain good health, reduce the risk of some diseases like cardiovascular disease and Type 2 diabetes, and reduce risk factors for overweight or obesity.152 153 Between 2017 and 2023, most local middle and high school students reported consuming fruits at least once a week. Fewer students reported eating vegetables at least once a week. 21% 11% 22% 0% 5% 10% 15% 20% 25% 2016-2017 2018-2019 2020-2021Percent of adultsYear Figure 71: Percent of Adults Who Are Binge Drinkers* in Gallatin, Madison, and Park Counties, MT from 2016 to 2021 Source: Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention*Binge drinking is defined as males having five or more drinks in one occasion and females having four or more drinks in one occasion 87 In 2022, 12% of Gallatin County residents lacked access, at times, to enough food for an active and healthy life. This was similar to the rates in Montana and the United States. During a 2024 community focus group, participants discussed their experiences of compromising quality for quantity and choosing less healthy options due to cost. 6% 31%35% 27% 11%8% 36% 40% 31% 14% 7% 33% 44% 35% 11%9% 46% 41% 32% 17% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% I did not eat fruit in the last 7 days I did not eat any carrots in the last 7 days I did not eat any potatoes in the last 7 days (excludingfrench fries, fried potatoes,or potato chips) I did not eat salad in the last 7 days I did not eat vegetables other than salad, potatoesor carrots in the last 7 daysPercent of surveyed studentsFigure 72: Percent of Surveyed Middle School Students Not Consuming Fruits or Vegetables in the Last 7 days in Gallatin County, MT from 2017 to 2023 2017 2019 2021 2023 Source: Youth Risk Behavior Survey, Centers for Disease Control and Prevention 6% 35% 27%25% 8%9% 39%35% 27% 13% 8% 38% 33%31% 11%7% 38% 30%27% 11% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% I did not eat fruit in the last7 days I did not eat any carrots inthe last 7 days I did not eat any potatoesin the last 7 days (excludingfrench fries, fried potatoes, or potato chips) I did not eat salad in thelast 7 days I did not eat vegetablesother than salad, potatoesor carrots in the last 7 daysPercent of surveyed studentsFigure 73: Percent of Surveyed High School Students Not Consuming Fruits or Vegetables in the Last 7 Days in Gallatin County, MT from 2017 to 2023 2017 2019 2021 2023Source: Youth Risk Behavior Survey, Centers for Disease Control and Prevention 88 Data describing healthy eating and food insecurity were not available at the demographic and geographic subgroup levels for Gallatin County, though national research shows that individuals with lower incomes and those living in areas with limited access to healthy foods are less likely to follow a diet that aligns with the current U.S. Dietary Guidelines.154 UNDERSTATING HEALTH BEHAVIORS How individuals interpret and make meaning from health-related information can influence decisions they make about how to behave, and these decisions can impact their health outcomes,155 though more research is needed to fully understand how understanding health behaviors impacts health outcomes.156 157 158 Unfortunately, there were no existing data available for Gallatin County about how the community understands health behaviors. This report explores this topic by examining data on specific behaviors that were highlighted by the community committee, including concussions, sleep, and sexual activity. During a 2024 community focus group, it became evident that members of the community were aware of the differences between healthy and unhealthy behaviors. However, due to the high cost of living and other factors, they often were forced to prioritize affordable basic health needs while neglecting others. Concussions and other traumatic brain injuries can have negative cognitive, behavioral/emotional, and physical effects that affect interpersonal, social, and occupational functioning.159 Around 1 in 5 middle and high school students reported having experienced at least one concussion from playing a sport or being physically active in 2023, which has not changed drastically since 2017. 12.0%12.3%12.9% 0% 2% 4% 6% 8% 10% 12% 14% 16%Percent of residentsFigure 74: Percent of Residents Experiencing Food Insecurity* in Gallatin County, MT, Statewide, and the United States in 2022 Gallatin County Montana United States Source: Mapthe Meal Gap, Feeding America*Defined as the lack of access, at times, to enough food for an active, healthy life 89 Children and adolescents who do not get adequate sleep are at higher risk for developing obesity, Type 2 diabetes, poor mental health, injuries, and negative mental health outcomes, including increased suicidality.160 161 162 163 Sixty-eight percent of high school students and 54% of middle school students reported sleeping less than eight hours per night. This has remained fairly consistent for high school students between 2017 and 2023, though the percent of middle school students that are sleeping less than eight hours has increased by 14% since 2017. Data about sleep behaviors were not available at the demographic and geographic subgroup levels for Gallatin County, though national research has found that Black adolescents, youth from lower income families, youth with higher a body mass index, and boys slept less than their counterparts.164 17% 18% 17% 20% 17% 20% 17%18% 15% 16% 17% 18% 19% 20% 2017 2019 2021 2023 Percent of surveyed studentsYear Figure 75: Percent of Surveyed Students Reporting at Least One Concussion from Playing a Sport or Being Physically Active in Gallatin County, MT from 2017 to 2023 Middle School High School Source:Youth Risk Behavior Survey, Centers for Disease Control and Prevention 40%43%49%54% 64%66%69%68% 0% 10% 20% 30% 40% 50% 60% 70% 80% 2017 2019 2021 2023Percent of surveyed studentsYear Figure 76: Percent of Surveyed Students Sleeping Less than 8 Hours per Night, on Average in Gallatin County, MT from 2017 to 2023 Middle School High School Source:Youth Risk Behavior Survey, Centers for Disease Control and Prevention 90 Youth sexual activity, especially without the use of proper protection and screening, can increase the risk of HIV and other sexually transmitted infections and unintended pregnancies.165 Thirty-four percent of high school students and 12% of middle school students reported having had sexual intercourse as of 2023. Thirteen percent of high school students and 4% of middle school students reported that they, or their partner, did not use a condom the last time they had sexual intercourse. Seven percent of high school students and 2% of middle school students reported using drugs or alcohol before the last time they had intercourse. Seventeen percent of high school students and 3% of middle school students reported having sexual intercourse with more than one person. The percent of high school students that reported being sexually active, and having more than one partner, has decreased since 2017. 7% 1%1%2% 13% 4%3% 5% 10% 1%1% 4% 12% 3%2% 4% 0% 5% 10% 15% I have had sexual intercourse I have had sexual intercourse with more than one person I used alcohol or drugs before the last time I had sexual intercourse I (or my partner) did not use a condom the last time we had sexual intercoursePercent of surveyed studentsSurvey response Figure 77: Sexual Activity Indicators among Surveyed Middle School Students in Gallatin County, MT from 2017 to 2023 2017 2019 2021 2023 Source:Youth Risk Behavior Survey, Centers for Disease Control and Prevention 37% 22% 6% 14% 41% 23% 7% 15% 37% 18% 7% 14% 34% 17% 8% 13% 0% 10% 20% 30% 40% 50% I have had sexual intercourse I have had sexual intercourse with more than one person I used alcohol or drugs before the last time I had sexual intercourse I (or my partner) did not use a condom the last time we had sexual intercoursePercent of surveyed studentsSurvey response Figure 78: Sexual Activity Indicators among Surveyed High School Students in Gallatin County, MT from 2017 to 2023 2017 2019 2021 2023 Source:Youth Risk Behavior Survey, Centers for Disease Control and Prevention 91 Data about understanding healthy behaviors were not available at the demographic and geographic subgroup levels for Gallatin County, though national research shows that older adults, American Indian and Alaska Native children and adults, military service members, survivors of intimate partner violence, people who experience homelessness, and people in correctional or detention facilities have higher rates of traumatic brain injury, including concussions, than their peers.166 PHYSICAL ACTIVITY According to the CDC, being physically active is one of the most important things an individual can do to impact their health.167 The Physical Activity Guidelines for Americans reported that studies have shown regular physical activity can impact health in many ways, such as reducing all-cause mortality, reducing the risk of some diseases like cardiovascular disease and some cancers, reducing risk factors for disease such as hypertension, improving physical fitness, improving an individual’s ability to engage in activities needed for daily living, improving brain health and conditions that affect cognition, and reducing falls and injuries from falls.168 Fourteen percent of the adult population in Gallatin, Madison, and Park Counties reported not completing any exercise in the last 30 days from 2016 to 2021. There are disparities among age groups, with individuals aged 18 to 24 and over 65 years old being less likely to have exercised in the last 30 days. During a 2024 community focus group, participants shared various physical activity-related experiences. One individual discussed their struggles with weight loss and exercise, while another highlighted the positive impact that exercising had on their health over the past year or two. Additionally, a few participants mentioned that they were not able to afford a gym membership while prioritizing other health needs like food, medications, and doctor appointments. 25% 11% 9% 14% 16% 21% 0%5%10%15%20%25%30% 18-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65+ years Percent of age groupAge groupFigure 79: Percent* of Adult Population that Report Not Completing Any Exercise in the Last 30 days by Age Group in Gallatin, Madison, and Park Counties, MT in 2016-2021 Source:Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention *Estimates do not factor in weighting variables 92 In 2023, 72% and 73% of surveyed Gallatin County middle and high school students, respectively, reported not being physical active for at least 30 minutes per day in the last week. Physical inactivity has increased slightly since 2017. Data about physical activity were not available at the demographic and geographic subgroup levels for Gallatin County, though national research shows that household income can impact youth physical activity and sports participation.169 National research also has found disparities in physical activity among racial and ethnic groups, as Hispanic, non-Hispanic Black, and Non-Hispanic Asian adults were less likely to engage in sufficient physical activity compared to White adults.170 66%72%71%72%71%71%69%73% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2017 2019 2021 2023Percent of surveyed studentsYear Figure 80: Percent of Surveyed Students That Report Not Being Physically Active for at Least 60 Minutes per Day in the Last Week in Gallatin County, MT from 2017 to 2023 Middle School High School Source: Youth Risk Behavior Survey, Centers for Disease Control and Prevention 93 ACCESS TO SERVICES Access to services is anything relating to the direct medical treatment or testing of patients. Access to affordable, quality healthcare can prevent disease and lead to earlier disease detection. Communities are living longer lives because of breakthroughs in clinical care, such as advancements in vaccinations, surgical procedures, and preventative screenings. WHAT IS THE PURPOSE OF THIS TOPIC AND WHAT DO WE WANT TO KNOW? It is important to explore and assess access to services to ensure equitable, effective, and responsive health system delivery within a community. Specifically, understanding access disparities helps identify underserved populations, access directly impacts health outcomes, and access informs resource allocation to help direct resources where they are needed most, optimizing service delivery. BRIEF INTRODUCTION OF METRICS This community health assessment explored access to services related to influences to access (positive and negative barriers to accessing programs and services), access to the mental health services, cost of services, and access to social services in Gallatin County. WHAT DID WE LOOK AT? Influences to access are the positive facilitators and the negative barriers to individuals accessing a diverse range of health-related programs and services in their community. These influences range from linguistic access and current policy landscape, to perceptions, stigma, inclusivity, cost, insurance coverage, and transportation. Access to mental health services is an individual’s ability to reach local programs and care providers that are relevant, available, affordable, and accessible for the spectrum of mental health needs, including programs for managing mental health, programs to provide acute and crisis care, and in-patient and out- patient services. Cost of services is the financial burden individuals experience to receive the healthcare and health- related programs they need and require, and which are available in the community. Access to social services is an individual’s ability to reach local federally-funded/subsidized social services (such as Medicaid, Supplemental Nutrition Assistance Program (SNAP) and Women, Infants, and Children (WIC)) for which they are eligible. Access includes an individual’s awareness of programs and adequate service provider participation in such programs. WHY WE LOOKED AT IT These topics were identified by the Community Committee after the committee generated several ideas and themes related to access to services. The committee was asked to rank themes based on those that had the most influence on health, and the ability for the community to have impact in these factors. 94 WHAT PUBLIC HEALTH KNOWS ABOUT THE IMPORTANCE OF THIS Public health recognizes the importance of access to services in promoting overall well-being and reducing health disparities. Access to services ensures that vulnerable populations can receive necessary care. Barriers such as economic, geographic, and cultural factors can limit access for many individuals. For example, the affordability to healthcare affects individuals’ ability to seek medical care and disparities in access or quality of care can lead to differential health outcomes. BRIEF NARRATIVE (LINKS TO SOCIAL DETERMINANTS OF HEALTH) Access to social services and healthcare services, such as mental healthcare, plays an important role in in addressing underlying factors that affect health, such as housing, nutrition, and employment. Social services promote equity and help bridge gaps, ensuring that vulnerable populations receive the support they need.171 Opportunities to combine access to healthcare and clinical services adopts a holistic approach to health that recognizes that health extends beyond access to healthcare services and involves other influential factors (such as influences to access as discussed later in this section). Moreover, access to healthcare services is essential to achieving the best possible health outcomes. Lack of health insurance, poor access to transportation services, and limited healthcare resources can prevent individuals from receiving the care needed.172 Addressing these factors is critical to ensuring all individuals can achieve optimal health. For example, having insurance is associated with earlier detection of diseases and reduced risk of significant adverse health events. Expanding access to health and social services is a step towards reducing health disparities, as highlighted in Health People 2030. FRAMING TOPIC FROM THE LITERATURE Research indicates that modifiable factors contributing to an individual’s length and quality of life include clinical care (20%) and access to quality care (10%), with their associated weights expressed as percentages.173 LOCAL DATA DISCUSSION The community health assessment explored existing data from Gallatin County, and where feasible differences between subgroups and geographic areas were reviewed. INFLUENCES TO ACCESS Studies have shown that individuals with regular access to healthcare services tend to have better health outcomes.174 Conversely, those with infrequent visits may experience worsening health conditions due to delayed diagnosis or treatment. The frequency of medical visits over the past two years can significantly influence access to healthcare. Frequent medical visits for regular monitoring of health conditions and preventative care can lead to early detection of potential health risks. Regular medical visits can improve an individual's health literacy making it more likely that individuals understand recommended treatment plans, if required, and the importance of following medical advice.175 Consistent appointments also build trusting relationships which can create opportunities for individuals to seek care and communicate openly about needs and health concerns.176 The frequency of appointments also can highlight barriers to access, for example, transportations issues, high costs, 95 insurance coverage gaps, or lack of insurance coverage. According to the most recent data from the Behavioral Risk Factor Surveillance System, 18% of adults in Gallatin, Madison, and Park Counties had not had a doctor’s appointment in two or more years. Healthcare affordability refers to the cost of healthcare services, health insurance premiums, deductibles, co-pays, or co-insurance and the ability to pay for these. While health insurance coverage may increase an individual’s ability to afford healthcare costs; even among those with health insurance, many experience financial hardship due to high costs of insurance copays and deductibles.177 Gallatin County consistently has lower uninsured rates compared to Montana and the United States, where in 2022, Gallatin County was around 6%, while Montana and the United States had rates around 8%. The process of Medicaid “unwinding" began on April 1, 2023. This unwinding increased the number of uninsured individuals. However, the full impacts on uninsured rates remain uncertain.178 21% 17%18% 0% 5% 10% 15% 20% 25% 2016-2017 2018-2019 2020-2021Percent of adultsYear Figure 81: Percent of Adults without A Medical Provider's Appointment in 2+ Years in Gallatin, Madison, and Park Counties, MT from 2016 to 2021 Source:Behavioral Risk Factor Surveillance System, Centers for Disease Control an d Prevention 96 Data were available for select race/ethnicity subgroups, specifically for Hispanic and Latino residents who were uninsured from 2013-2022. Over time in Gallatin County, the percentage of uninsured Hispanic and Latino individuals has gradually decreased from its peak (39%) in 2015 to 17% in 2022. In 2022, the uninsured rate for Hispanic and Latinos in Gallatin County (17%) was higher than Montana (10%) and equal to that of the United States (17%). Data were also available for disabled residents who were uninsured from 2015-20022. People with disabilities are more likely to have an annual household income of less than $15,000 annually (22.3% of households) compared to people without disabilities (7.3% of households).179 For individuals with disabilities, financial and social barriers can have a more significant impact, resulting in decreased 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022Percent of populationYear Figure 82: Percent of Population without Health Insurance in Gallatin County, MT, Statewide, and the United States from 2013 to 2022 Gallatin County Montana United States Source: United States Census Bureau, American Community Survey 5-year estimates 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022Percent of populationYear Figure 83: Percent of Hispanic or Latino Residents Who Were Uninsured in Gallatin County, MT, Statewide, and the United States from 2013 to 2022 Gallatin County†Montana United States Source: United States Census Bureau, American Community Survey 1-year estimates†Data for Gallatin County are suppressed in 2014, 2016-2018 and 2021 97 functioning.180 Insurance access can help address this barrier by providing access to necessary medical care, assistive devices, and other support services.181 According to Bozeman Health’s 2023 Community Needs Assessment, based on those who indicated a need to delay or not receive healthcare services (n=264), the most frequent reason cited for delaying healthcare services was cost (49.6%) and insurance not covering the service (33%). Limited access to certain types of healthcare providers can affect overall health outcomes. Healthcare availability is often defined as the geographic proximity of providers in relation to an individual and is a reflection of the capacity of the medical service system to adequately meet the needs of the population.182 183 For example, strong primary and emergency care resources can help manage acute conditions and provide preventative care which are crucial for addressing health needs and providing continuous care, whereas limited access to pediatricians and psychiatrists may lead to challenges 0% 2% 4% 6% 8% 10% 12% 2015 2016 2017 2018 2019 2020 2021 2022Percent of populationYear Figure 84: Percent of Residents with Disabilities Who Were Uninsured in Gallatin County, MT, Statewide, and the United States from 2015 to 2022 Gallatin County Montana United States Source: United States Census Bureau, American Community Survey 1-year estimates 50% 33% 25% 22% 12% 0%10%20%30%40%50%60% It costs too much My insurance didn't cover it Could not get an appointment Too long to wait for an appointment No insurance Percent of respondentsReasonFigure 85: Top Reasons for Delaying Needed Healthcare in Gallatin County, MT as of 2023 Source:Bozeman Health Community Health Needs Assessment 98 addressing children’s health and mental health needs. This healthcare availability indicator is often defined as the number of physicians per 100,000 population. The number of primary care physicians in Gallatin County is slightly lower (75 per 100,000) than the state average (85 per 100,000), whereas Gallatin County has a higher number of obstetrics and gynecologists (19 per 100,000) compared to the state (10 per 100,000). The figure below suggests potential disparities in access to certain specialized care which could lead to longer wait times, delayed care, and longer travel distances for those needing these services. Research on healthcare access disparities highlights variations in emergency department visits. Key findings include that American Indian/Alaska Native populations may face barriers to accessing primary care services, leading to higher reliance on emergency departments for acute health needs. Limited access to healthcare facilities, transportation challenges, and geographic isolation can contribute to this disparity.184 While these points provide context, data are not available for Gallatin County to explore these disparities further. Despite a decrease in emergency department visits from 2019 (1,511 visits) to 2020 (975 visits) among American Indian or Alaska Native individuals, they still had the highest rate of emergency department visits by race/ethnicity in Gallatin County. In 2020, the Hispanic population had the second-highest rate of emergency department visits after removing the “other” category summarized in Figure 87. 14 75 35 11 24 20 24 11 86 46 8 16 10 26 0 10 20 30 40 50 60 70 80 90 100 Pediatric Primary Care Family Medicine Psychiatry Emergency Medicine Obstetrics and Gynecology Internal MedicinePhysicians per 100,000Physician Type Figure 86: Number of Physicians by Type per 100,000 Residents in Gallatin County, MT, and Statewide as of 2022-2023 Gallatin County Montana Source: Health Resources and Services Administration, Area Health Resources Files 99 ACCESS TO MENTAL HEALTH SERVICES Access to mental health services is an individual’s ability to reach local programs and care providers that are relevant, available, affordable, and accessible for the spectrum of mental health needs, including programs for managing mental health, programs to provide acute and crisis care, and in-patient and out- patient services. The behavioral health system serving Gallatin County has been put under significant stress driven by demand for services in part by a growing population, an increased need for services, and a challenging array of sustainable funding sources available to sustain the system. In Gallatin County, community coalitions like the Gallatin County Behavioral Health Coalition and the Gallatin Local Mental Health Advisory Council include key partners such as government officials, healthcare providers, community members, and mental health practitioners. These coalitions actively collaborate to address gaps in services, recognizing that solutions are neither simple nor quick. Available data discussed earlier in the report provide evidence of the scale of the mental health access problem, including the age-adjusted, reported suicide rate in Gallatin County from 2016-2022 which remains lower than the statewide figures, but remains a cause for concern at nearly double the national suicide rate (see Figure 50). As previously discussed in this section, access to healthcare providers can affect overall health outcomes. The number of residents per mental healthcare provider is an indicator frequently used to assess access to health services. Limited availability of mental healthcare providers, including the number of mental healthcare providers, increases the risk of poor health outcomes.185 Gallatin County consistently had a lower number of residents per mental healthcare provider compared to both statewide and national data from 2016 to data for 2023. The trend also showed a decline in the number of residents per provider over the years for all three geographic areas. 474 778 510 169 537 1,511 400 360 556 141 513 975 0 200 400 600 800 1,000 1,200 1,400 1,600 White Black Other Asian or PacificIslander Hispanic American Indianor Alaska NativeRate per 1,000Race/Ethnicity Figure 87: Emergency Department Visits per 1,000 Medicare (dual and non-dual) Beneficiaries by Race/Ethnicity in Gallatin County, MT from 2019 to 2020 2019 2020 Source:Social Determinants of Health Database,Agency for Healthcare Research and Quality 100 In Bozeman Health’s Community Health Needs Assessment (2023), respondents who did not access mental health services (n=463) cited cost as a barrier (18%, n=80), followed by “didn’t know where to go” (7%, n=31). Concerns with the behavioral healthcare system are interwoven with concerns related to substance abuse disorders. Substance abuse indicators discussed in the Health Behaviors section identify a concern among youth, where almost 1 in 4 high school students and 1 in 5 middle school students have been offered, sold, or given illegal drugs on school property in the past year (see Figures 65 and 66). A sufficient number of substance abuse service facilities accepting Medicaid in a community can be important to close the treatment gap and preventing deaths. While local data are not available, nationally, fewer than 13% of the 21 million plus individuals who need substance use services receive 390 370 340 320 300 270 250 230 410 380 360 330 320 300 280 270 500 470 440 400 380 350 340 320 0 100 200 300 400 500 600 2016 2017 2018 2019 2020 2021 2022 2023Residents per providerYear Figure 88: Number of Residents per Mental Healthcare Provider in Gallatin County, MT, Statewide, and the United States from 2016 to 2023 Gallatin County Montana United States Source: CMS National Provider Identification 75% 18% 7%7%5%3% 0% 10% 20% 30% 40% 50% 60% 70% 80% Not needed It costs too much Don't know where to go Feel it would not help Lack of nearby services Stigma attached to mental healthPercent of respondentsReason Figure 89: Top Reasons for Not Accessing Mental Health Services in Gallatin County, MT as of 2023 Source:Bozeman Health Community Health Needs Assessment 101 any treatment.186 Increasing the availability of service providers who accept Medicaid, can bridge the treatment gap and ensure more individuals access the care needed.187 188 In Gallatin County, the rate of substance abuse service providers accepting Medicaid per 1,000 people has increased ranging from 0.010 to 0.035. From 2010-2013, the acceptance rate remained consistently low, hovering around 0.010. After 2016, the rate steadily rose each year, reaching its highest point at just under 0.035. The upward trend suggests a shift in policy, funding, and/or demand for services. Additional assessment is needed to better understand the change in service facility acceptance of Medicaid and its relation to availability of services and impacts on community health outcomes related to substance abuse. COST OF SERVICES Cost of services is the financial burden individuals experience to receive the healthcare and health- related programs they need and require, and which are available in the community. Cost of healthcare services is interwoven with access to health insurance coverage as discussed in the “Influences to Access” section. Although having health insurance can enhance an individual’s capacity to manage healthcare expenses, many people still face challenges due to high costs, even though they are insured.189 According to data available from the Behavioral Risk Factor Surveillance System, a health survey that looks at behavioral risk factors, 10% of Gallatin, Madison, and Park Counties’ adults who participated were unable to see a doctor due to costs, a 2% decrease from 2018-2019. 0 0.005 0.01 0.015 0.02 0.025 0.03 0.035 0.04 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020Rate per 1,000Year Figure 90: Substance Abuse Service Facilities Accepting Medicaid per 1,000 in Gallatin County, MT from 2010 to 2020 Source:Social Determinants of Health Database,Agency for Healthcare Research and Quality 102 SOCIAL SERVICES Access to social services is an individual’s ability to reach local federally-funded/subsidized social services (such as Medicaid, Supplemental Nutrition Assistance Program (SNAP), and Women, Infants, and Children (WIC)) for which they are eligible. Access includes an individual’s awareness of programs and adequate service provider participation in such programs. Medicaid is a public insurance program that serves people with low incomes, covering approximately one in five individuals in the United States.190 It plays a crucial role in providing healthcare access, especially for children. In 2021, Medicaid covered four out of ten children in the United States,191 eight out of ten children living in poverty,192 one out of six adults,193 and nearly half of adults in poverty.194 Similar data were not readily available for similar subgroups in Gallatin County. In Gallatin County, after the Medicaid “unwinding” process discussed earlier, the monthly enrollment numbers for both adults and children declined slightly. The peak enrollment occurred in April 2023 (with 3,538 enrollees), while the lowest point was in December 2023 (with 2,405 enrollees). 10% 12% 11% 0%2%4%6%8%10%12%14% 2020-2021 2018-2019 2016-2017 Percent of adultsYearFigure 91: Percent of Adults Unable to See a Medical Provider Due to Cost in the Last 12 months in Gallatin, Madison, and Park Counties, MT from 2016 to 2021 Source:Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention 103 Data were available for adults and children enrolled in traditional Medicaid in Gallatin County, specifically for individuals who are blind and disabled, women who are pregnant, and children in foster care. The number of enrolled residents in all three subgroups have remained relatively stable year after year with around 600 enrollees for individuals with disabilities, around 100 women who are pregnant, and around 300 enrollees for foster care. Public benefit programs providing food assistance have been associated with lower healthcare costs, lower healthcare utilization, and improved health outcomes.195 196 A study in 2017 of low-income adults participating in SNAP found an association between SNAP participation and lower healthcare 0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 Oct-21Nov-21Dec-21Jan-22Feb-22Mar-22Apr-22May-22Jun-22Jul-22Aug-22Sep-22Oct-22Nov-22Dec-22Jan-23Feb-23Mar-23Apr-23May-23Jun-23Jul-23Aug-23Sep-23Oct-23Nov-23Dec-23Number of enrolled residentsMonth/year Figure 92: Monthly Number of Adults and Children Enrolled in Traditional Medicaid in Gallatin County from October 2021 to December 2023 Traditional Medicaid Adults Traditional Medicaid Children Source: Montana Medicaid Enrollment Dashboard 0 100 200 300 400 500 600 700 Oct-21Nov-21Dec-21Jan-22Feb-22Mar-22Apr-22May-22Jun-22Jul-22Aug-22Sep-22Oct-22Nov-22Dec-22Jan-23Feb-23Mar-23Apr-23May-23Jun-23Jul-23Aug-23Sep-23Oct-23Nov-23Dec-23Number of enrolled residentsMonth/year Figure 93: Monthly Traditional Enrollments among Blind/Disabled Residents, Pregnant Women, and Children in Foster Care in Gallatin County from October 2021 to December 2023 Blind & disabled adults/children Pregnant women Foster care Source: Montana Medicaid Enrollment Dashboard 104 expenses.197 Similarly, a 2018 study found 5.8 percent lower expenses among older adult SNAP participants who were hospitalized as compared to hospitalized older adults without SNAP.198 WIC has also been associated with improved health outcomes.199 200 Specific demographic or subgroup data were not available, however Gallatin County started above 6% of the population with cash assistance or SNAP in the past 12 months in 2013 and generally declined overtime reaching around 4% of the population in 2022. According to 2023 data from the National Database of Childcare Prices, the median cost of home- or center-based care for infants, toddlers, or preschoolers was $10,815 in Gallatin County, which equates to about 13% of a household’s median income (based on 2022 census data).201 According to the U.S. Department of Health and Human Services, childcare is considered affordable if it costs no more than 7% of a family’s income.202 The 2023 data indicated that median childcare costs within Gallatin County were about 45% higher than the statewide average and 34% higher than the nationwide average. A report by the Montana Department of Labor and Industry indicated that as of 2023, licensed childcare capacity only met 44% of the statewide estimated demand and 62% of Gallatin County’s demand.203 Similar trends are observed nationally as well; according to a 2024 survey among more than 10,000 early childhood educators, 53% reported staffing shortages and 56% reported under-enrollment due to the limited capacity.204 Increasing costs paired with decreasing availability pose major challenges for families needing childcare and can cause negative impacts at the state and national levels as well. A Montana Department of Labor and Industry reported and a similar publication by the White House highlight that a lack of high-quality, affordable childcare also can negatively impact the overall economy by preventing parents from participating in the labor force.205 206 0% 2% 4% 6% 8% 10% 12% 14% 16% 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022Percent of populationYear Figure 94: Percent of Population with Cash Public Assistance or SNAP in the Past 12 Months in Gallatin County, MT, Statewide, and the United States from 2013 to 2022 Gallatin County Montana United States Source: United States Census Bureau, American Community Survey 5-year estimates 105 SOCIAL AND ECONOMIC FACTORS Social and economic factors affect how well and how long we live. Social and economic factors include factors such as income, education, employment, community safety, and social support. The choices that are available in a community are impacted by social and economic factors. These aspects of well-being include, for example, the ability to afford medical care and housing. WHAT IS THE PURPOSE OF THIS TOPIC AND WHAT DO WE WANT TO KNOW? It is important to explore social and economic factors as part of the community health assessment to gain a comprehensive understanding of the conditions that influence health, behaviors, and lived experience in a community. BRIEF INTRODUCTION OF METRICS This community health assessment looked at cost of living, housing, and employment data for Gallatin County. The assessment of social and economic factors included community focus group discussions as well as information from the United States Census Bureau, the Gallatin County Housing Needs Assessment, and Montana Department of Labor and Industry. WHAT DID WE LOOK AT? Housing affordability is the ability to buy or rent a reasonable, safe place to live that does not impose disproportionate financial burden or inhibit the pursuit of other nondiscretionary spending and reasonable financial goals. Typically, housing is affordable if housing cost does not exceed 30%of income.207 Severe housing burden is when more than 50% of income is spent on housing costs.208 $13,087 $10,081 $11,451 $9,409 $9,116 $6,907 $7,976 $6,447 $9,700 $7,522 $8,474 $7,021 $0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000 Center-based infant Home-based infant Center-based toddler and preschool Home-based toddler and preschoolAnnual cost (2023 dollars)Figure 95: Annual Childcare Cost by Age of Child and Care Setting* in Gallatin County, MT, Statewide, and the United States in 2023 Gallatin County Montana United States Source: National database of childcare prices, Women's Bureau, United States Department of Labor *Center-based: non-residential settings; infants: ages 0-23 months; toddlers: ages 24-35 months, preschool: ages 36-60 months 106 Cost of living is the financial resources needed for maintaining a certain standard of daily living in a location. Cost of living includes both the real cost of daily living expenses, and the wages needed to support such expenses.209 Employment is the exchange of time and labor for monetary compensation.210 The common expectation is that, depending on household size, individuals should be able to balance the income generated and the cost of daily living in a community when employed in one local, full-time job. Employment provides income that can support healthy lifestyle choices.211 WHY WE LOOKED AT IT These topics were selected by the Community Committee. The committee was asked to choose topics that they felt strongly influenced the health of Gallatin County and were also issues that we have the ability to address. WHAT PUBLIC HEALTH KNOWS ABOUT THE IMPORTANCE OF THIS It is well established that the social and economic factors within communities can influence individual and community health outcomes. 212 213 FRAMING TOPIC FROM THE LITERATURE Research has indicated that between 35% to 47% of the modifiable factors influencing health stem from social and economic factors.214 215 BRIEF NARRATIVE (LINKS TO SOCIAL DETERMINANTS OF HEALTH) Social and economic factors are key aspects of the social determinants of health. They encompass the financial factors, personal interactions, and the built environment of a community.216 If individuals and families can earn a steady income that is on par with the local cost of living, they can afford the goods and services that allow them to meet their health needs.217 Otherwise, there is the risk of poverty, food insecurity, inadequate access to care, and unemployment.218 Housing is also crucial, and it must be both safe and affordable to meet the needs of the community.219 Social and economic factors share the environment in which people spend their lives, which impact their behaviors and their opportunities. LOCAL DATA DISCUSSION This community health assessment explored existing data from Gallatin County, looking at differences between subgroups and geographic areas when that information was available. HOUSING AFFORDABILITY Housing affordability is a critical factor influencing health outcomes, as financial strain from high housing costs can lead to significant stress and limited access to essential resources.220 These resources can include healthy food, healthcare, and medications; and their absence can lead to malnutrition, unmanaged chronic conditions, and poor health outcomes.221 Higher cost of living increases the burden that housing has on the population. Housing costs may have both direct and indirect effects on mental 107 and physical health.222 Chronic diseases such as heart disease become more prevalent in households burdened by housing costs.223 Housing affordability is also interconnected with the community context, housing quality and housing affordability. Information about housing costs in Gallatin County is included in the community health assessment under the Community Context section. Information about housing quality and availability is addressed in the pages below under Environmental Factors section. Beyond physical consequences, the stress associated with housing insecurity and being unable to afford housing can put a strain on mental health and may lead to anxiety and depression, both of which can, in turn, affect overall physical well-being.224 Unstable housing also has the potential consequence of disrupting employment, education, and access to healthcare.225 226 227 Ensuring that housing is affordable and thus more stable for individuals is not just an economic issue, but crucial to overall well- being and health. Focus groups were held in the community to discuss how the cost of living and housing affordability impacted health in Gallatin County. During these conversations, housing instability emerged as a significant stressor, with many participants reporting fears of losing their homes, which created a sense of impending crisis. A general feeling of hopelessness pervaded, as people worried about ever being able to afford a home due to persistently high housing costs and interest rates. These financial pressures contributed to physical and mental health issues such as stress, anxiety, high blood pressure, and even chronic conditions like diabetes and weight gain. In 2022, 37% of housing occupants in Gallatin County were renters while 63% owned the housing they inhabited. In contrast, a higher percentage of people across Montana and the United States own their homes than in Gallatin County. 63% 37% 69% 31% 65% 35% 0% 10% 20% 30% 40% 50% 60% 70% 80% Owner occupied Renter occupiedPercent of housing unitsOccupant type Figure 96: Percent of Housing Units by Occupant Type, Gallatin County, MT, Statewide, and the United States in 2022 Gallatin County Montana United States Source: UnitedStates Census Bureau, American Community Survey, 5-year Estimate 108 The median home sale prices across subdivisions in Gallatin County and for the county overall were documented for 2023. The median sale price for the entire county was $662,000. This price was higher than the median home sale price in the United States overall which was $514,000. Big Sky in particular had a median home sale price that was over double that of the national median. Between 2018 and 2023, 47% of renters paid more than 30% of their income on rent. This percentage is just under the U.S. percentage and just over that of Montana. Census data stated that 31% of homeowners in Gallatin County paid more than 30% of their income on their mortgage.228 $662,000 $730,000 $549,000 $594,000 $844,000 $393,000 $1,323,500 $611,000 $514,000 $0 $200,000 $400,000 $600,000 $800,000 $1,000,000 $1,200,000 $1,400,000 GallatinCounty Bozeman Belgrade Manhattan GallatinGateway Three Forks Big Sky WestYellowstone UnitedStatesMedian home priceCommunity Figure 97: Median Home Sale Price by Community in Gallatin County, MT and the United States as of 2023 Source: DRAFTGallatin County Housing Needs Assessment, Economic & Planning Systems, Inc. and United States Census 53% 47%45%45% 51%50% 0% 10% 20% 30% 40% 50% 60% 2013-2017 2018-2022Percent of rentersYear Figure 98: Percent of Renters Spending >30% of Income on Rental Costs in Gallatin County, MT, Statewide, and the United States from 2013 to 2022 Gallatin County Montana United StatesSource: UnitedStates Census Bureau, American Community Survey 5-year Estimates 109 As previously noted in Figure 15, the median annual household income in Gallatin County in 2022 was $83,343. When looking at census data from the past five years, the median mortgage in Gallatin County was $2,064,229 and the median rent was $1,405.230 We acknowledge that although this is the most recent data, Gallatin County is growing rapidly, and this median may have changed since the compilation of this report. COST OF LIVING Cost of living includes the cost of food, goods, access to care, and the cost of services.231 When cost of living is high it can make affording these necessities difficult which may have negative effects on physical, mental, and social health.232 Cost of living can also affect different subpopulations unequally, as individuals with lower incomes experience larger financial impacts when costs of goods and services increase.233 Focus groups were held in the community to discuss how cost of living impacted health in Gallatin County, and participants talked about how the rising cost of living negatively affected their health in multiple ways. Many participants shared that they were forced to compromise on food quality, choosing less healthful options to stretch their grocery budgets due to high costs. One participant shared, “we're not buying as much of our meat from the Co-op anymore, now we’re buying it from Costco.” Participants also noted that the lack of nearby stores added to the challenge, as transportation costs, especially for gas, increased the expenses associated with accessing healthful food. Additionally, the dispersion of housing and employment locations further raised transportation expenses, which contributed to the overall high cost of living. This issue was particularly acute for students, seniors, and those living in rural areas. Some participants reported not having health insurance and being unable to afford medical tests, medications, or preventive services. This situation was especially concerning for non-English speakers, who faced language barriers and lacked adequate support to navigate these challenges, as well as for seniors who felt forced to prioritize prescriptions or could not afford care for disabilities. One focus group participant shared: “The first thing that comes to mind is people on fixed incomes like our seniors or those that are disabled because that you know when your cost of living goes up, you know their incomes aren't changing and so the all of those sacrifices that you have to make in order to and the choices that you have to make right then you have to prioritize what you're going to give up, and that might mean not getting a prescription to get one that is absolutely necessary or not going to the doctor or those kinds of things.” Participants expressed the high cost of living led them to skip social events, impacting their sense of community and connection. Many noted that friends and family had either left the area or lived far away, diminishing their motivation to meet new people due to concerns about potentially having to move away themselves. This fear of leaving Gallatin County because of financial constraints contributed to a sense of instability and unease about their long-term prospects in the community. Similar to housing affordability, the high cost of living contributed to physical and mental health issues such as stress, anxiety, high blood pressure, and chronic conditions like diabetes and weight gain. One 110 participant said, “I do have anxiety, I do worry more and lose more sleep and wonder, oh, can I pick up one more job where I can just work a few extra hours a week and have extra money coming in?” Overall, the high cost of living led to a sense of isolation, chronic health problems, and fear of an uncertain future for many in the community. EMPLOYMENT Employment plays a crucial role in ensuring that people are able to live healthy lives because it provides financial stability and allows them to afford the resources that they need to improve their well-being.234 Depending on the quality, security, and type of employment that one has, their income changes.235 This income then determines what health-improving resources they can afford. For example, being unemployed or working part time is correlated with increased rates of stress, depression, unhealthy eating, and increased substance use.236 On the other hand, working 55 or more hours a week may increase the risk of ischemic heart disease and stroke.237 Additionally, the type of job someone has can further impact health, as positions that involve physical labor may lead to higher rates of injuries and chronic pain, while jobs that are primarily sedentary can contribute to issues like obesity and cardiovascular diseases.238 239 According to the World Health Organization: “certain occupational risks, such as injuries, noise, carcinogenic agents, airborne particles, and ergonomic risks account for a substantial part of the burden of chronic diseases: 37% of all cases of back pain, 16% of hearing loss, 13% of chronic obstructive pulmonary disease, 11% of asthma, 8% of injuries, 9% of lung cancer, 2% of leukemia, and 8% of depression.”240 Ensuring that employment is safe, steady, and provides sufficient income to cover health needs is crucial in protecting overall well-being.241 There was not local data showing how employment in Gallatin County, which is discussed in the Community Context section of this report, impacts health outcomes for this community. ENVIRONMENTAL FACTORS The physical environment is where individuals live, learn, work, and play. People interact with their physical environment through the air they breathe, the water they drink, the homes in which they live, and the transportation they use. WHAT IS THE PURPOSE OF THIS TOPIC AND WHAT DO WE WANT TO KNOW? Exploring environmental factors in a community health assessment is crucial for identifying and mitigating health risks, preventing disease, and supporting informed public health decisions and resource allocation in a community. BRIEF INTRODUCTION OF METRICS This section examines transportation, housing quality, housing availability, and water supply. Further, this section examines precipitation, climate, and physically and legally available water for present and future conditions of Environmental Factors in Gallatin County. 111 WHAT DID WE LOOK AT? Transportation is the infrastructure and mechanisms in a community that move individuals from one place to another whether through active transportation (walking, biking) or by public or personal vehicle. The expectation is that transportation can happen in a way that is safe and accessible for the individual, community, and environment. In exploring transportation within Gallatin County, indicators such as vehicle types used to commute, and seatbelt use among youth and adults were examined to gain insights into safety and transportation methods. Housing quality refers to the physical characteristics and comparative standard of materials, age, and durability of housing units in a community. Poor housing conditions, such as the presence of lead, mold, or asbestos, poor air quality, and overcrowding, can contribute to negative health outcomes.242 In examining housing quality indicators such as the age houses were built in Gallatin County was explored. Housing availability is the presence of safe, stable, and secure housing units on the market for purchase or rent at an affordable price. Focus groups were conducted across the county to explore how housing availability impacts health in Gallatin County. This section also explores homelessness, which refers to people who are staying in a shelter, living in transitional housing, or sleeping in a place that is not meant for human habitation (such as a car or outdoors).243 As previously defined in the Social and Economic Factors section, housing affordability is the ability to buy or rent a reasonable, safe place to live that does not impose disproportionate financial burden or inhibit the pursuit of other nondiscretionary spending and reasonable financial goals. Typically, housing is affordable if housing cost does not exceed 30% of income.244 Severe housing burden is when more than 50% of income is spent on housing costs.245 In exploring housing availability, three focus group discussions were conducted to explore how cost of living, discussed previously in the Social and Economic Factors section, and housing availability impact health of residents in Gallatin County. Water supply is the current and future availability of adequate, clean, safe, and affordable water for individuals in a community. Water supply can be impacted by factors such as population growth, climate, and pollution. Indicators such as precipitation patterns, climate, air quality, and long-range temperature trends, physically and legally available water, and water quality conditions were explored. Air quality index (AQI) refers to how clean or polluted the air is by measuring five major pollutants: ground-level ozone, particle pollution (also known as particulate matter/PM), carbon monoxide, sulfur dioxide, and nitrogen dioxide.246 Based on the levels of the five pollutants, the air quality index is then categorized on a qualitative scale ranging from “good” to “hazardous.” Data are reported in terms of the number of days per year in each air quality index category. WHY WE LOOKED AT IT These topics were selected by the Community Committee. The committee selected these factors because they have a strong influence on the health of Gallatin County and because the community believes they have the ability to impact these factors. 112 WHAT PUBLIC HEALTH KNOWS ABOUT THE IMPORTANCE OF THIS The physical environment, including factors like water quality, housing, and transportation, is known to impact both individual and community health outcomes.247 248 249 FRAMING TOPIC FROM THE LITERATURE Research clearly shows that environmental factors contribute to human illnesses, diseases, and death.250 251 These health impacts can also lead to significant economic and social consequences, including direct medical costs, lost time from school and work, and reduced economic productivity for individuals permanently affected by these factors.252 Research has indicated that between 3 to 5% of the modifiable factors influencing health stem from environmental health factors.253 254 BRIEF NARRATIVE (LINKS TO SOCIAL DETERMINANTS OF HEALTH) Environmental factors influence the health and well-being of communities.255 Factors such as water quality, water supply, housing conditions, transportation, and climate change all affect public health. These environmental factors are closely linked to social determinants of health such as economics, education, and access to healthcare. While individuals can take some actions to mitigate the impact of the environment on their health, many environmental factors are beyond an individual’s control such as air quality, housing conditions, and water quality. For example, unsafe or substandard housing can contribute to a range of health issues described later in this section. Addressing these environmental factors is important for reducing health disparities in a community. LOCAL DATA DISCUSSION The community health assessment explored existing data from Gallatin County, and where feasible, differences between subgroups and geographic areas were reviewed. TRANSPORTATION Motor vehicle crashes are a significant public health concern and a leading cause of death for individuals aged 1-54 in the United States. These injuries and fatalities are largely preventable.256 Proven strategies, such as the use of seatbelts, are highly effective in saving lives and reducing injuries. Studies show that seatbelt use can reduce serious crash-related injuries by about 50%.257 While seatbelt use data for demographic subgroups in Gallatin County is unavailable, national research indicates teenagers (aged 15-19) and young adults (aged 18-24) have the lowest seatbelt usage rates.258 In fatal accidents, almost half of the teen drivers and passengers were unrestrained at the time of crash.259 Survey data from Gallatin County shows an increase in the percentage of students who do not always wear a seatbelt when riding in a car. For middle school students, this percentage rose from 38% in 2017 to 53% in 2023. For high school students, it increased from 38% in 2017 to 42% in 2023. Among adults 113 surveyed in Gallatin, Madison, and Park Counties, the percentage who reported not always wearing a seatbelt while driving varied between 27% and 21% from 2016 to 2021. Transportation is critical to enable residents to access healthcare services and grocery stores as well as reach their jobs and other settings in the community.260 As of 2022, about 73% of Gallatin County residents commuted to work by driving alone in their car, truck, or van while only 9% carpooled with another person. Over the seven-year period from 2016 to 2022 census data indicated minimal change in overall commuting habits among Gallatin County residents. The most notable change was observed in 2020 when about 11% of residents reported working from home; the 4% increase from prior years can likely be attributed to the COVID-19 pandemic which enabled many employees to work remotely to avoid unnecessary workplace disease transmission. The rural nature of Gallatin County inhibits residents’ ability to walk to work and contributes to the lack of available public transportation options. 38%41%42% 53% 38%41%43%42% 0% 10% 20% 30% 40% 50% 60% 2017 2019 2021 2023Percent of studentsYear Figure 99: Percent of Surveyed Students Not Always Wearing a Seatbelt When Riding in a Car in Gallatin County, MT from 2017 to 2023 Middle School High School Source: Youth Risk Behavior Survey,Centers for Disease Control and Prevention 27% 21% 25% 0% 5% 10% 15% 20% 25% 30% 2016-2017 2018-2019 2020-2021Percent of adultsYear Figure 100: Percent of Adults Not Always Wearing a Seatbelt While Driving a Car in Gallatin, Madison, and Park Counties, MT from 2016 to 2021 Source: BehavioralRisk Factor Surveillance System, Centers for Disease Control and Prevention 114 Evaluating differences in health outcomes between residents of rural versus urban counties is important due to the additional barriers many rural residents face, like transportation challenges or limited access to services.261 In fact, according to 2016 data from the CDC, individuals in rural counties are 9% more likely to report having any disability type and 24% are more likely to report having three or more disabilities.262 HOUSING QUALITY Homes built before 1979 are more likely to contain lead-based paint263 and asbestos.264 When lead- based paint deteriorates or is found on surfaces that children can access or that receive frequent use, it becomes a significant hazard. Both lead and asbestos in homes pose serious public health risks due to their toxic properties, which can cause long-term health effects. The health impacts of lead and asbestos exposure are often not immediately noticeable, which can delay the identification of the source and result in prolonged exposure. Lead exposure can lead to developmental delays, learning disabilities, and behavioral problems in children,265 while asbestos exposure can cause respiratory diseases, including lung cancer.266 Understanding the age of the housing stock in a community is important for assessing community health risk related to these hazards. Housing quality is also interconnected with the community context, housing availability, and housing affordability. Information about housing costs in Gallatin County is included in the community health assessment in the Community Context section. Information about housing availability was addressed in this section and housing affordability is addressed in the previous Social and Economic Factors section. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Car, truck, or van- drove alone Car, truck, or van- carpooled Publictransportation(excludingtaxicab) Walked Taxicab,motorcycle,bicycle, or other Worked fromhomePercent of populationYear Figure 101: Percent of Residents Commuting to Work by Transportation Type in Gallatin County, MT from 2016 to 2022 2016 2018 2020 2022 Source: United States Census Bureau, American Community Survey, 5-year Estimates 115 In Gallatin County the percentage of homes that were owner-occupied in 2022 and built before 1979 was 24% (Figure 102). This rate is lower when compared statewide to Montana and the United States which were 46% and 48%, respectively. Further, in Gallatin County the percentage of homes built before 1979 that were renter-occupied was 37% in 2022, which is also lower than in Montana or the United States at 51% and 50%, respectively. Overall, both owner-occupied and renter-occupied homes in Gallatin County built before 1979 are less common compared to state and national percentages. Lastly, regardless of home ownership status in Montana or the United States, the percentage of homes built before 1979 is similar and varies between 46% and 51%. However, in Gallatin County, more renter-occupied homes were built before 1979 when compared to owner occupied homes. These data may be indicative of a rapidly growing community. HOUSING AVAILABILITY Housing availability plays a critical role in shaping health outcomes, extending beyond considerations of housing quality and affordability. Adequate housing availability ensures that individuals and families of all income levels have access to stable and secure living environments, which is fundamental for overall well-being.267 Limited housing availability can lead to overcrowding, displacement, and increased stress, all of which negatively impact mental and physical health.268 269 270 Insufficient housing options may force individuals into substandard living conditions that increase the risk of fall injuries due to poorly maintained or unsafe environments and exacerbate health issues by exposing them to environmental hazards such as mold, lead, or inadequate sanitation.271 Low housing availability also can force people to live in less desirable areas with reduced access to critical resources for health, such as healthcare, education, and nutritious food.272 This scarcity can also limit access to stable employment opportunities, as individuals may need to undertake longer commutes or accept less favorable job conditions to secure housing, thereby negatively impacting physical and mental health.273 274 275 Those experiencing homelessness, the most extreme form of housing insecurity, face higher rates of chronic and infectious diseases, mental health disorders, violence, and mortality.276 277 278 279 280 The ripple effects of 24% 37% 46%51%48%50% 0% 10% 20% 30% 40% 50% 60% Owner-occupied Renter-occupiedPercent of homesOccupant type Figure 102: Percent of Homes Built before 1979 by Occupant Type in Gallatin County, MT, Statewide, and the United States in 2022 Gallatin County Montana United States Source: United States Census Bureau, American Community Survey. 1-year Estimate 116 inadequate housing availability can undermine overall health through a complex interplay of economic, social, and environmental factors. Housing availability is also interconnected with the community context, housing quality, and housing affordability. Information about housing costs and homelessness in Gallatin County is included in the community health assessment under the Community Context section. Information about housing quality was addressed in the pages above and housing affordability is addressed under the previous Social and Economic Factors section. Focus groups were conducted across the county to explore how housing availability impacts health in Gallatin County. Participants voiced significant concerns about the current limited housing options, with many struggling to afford adequate housing and failing to qualify for subsidized options. As a result, these residents were often forced to accept substandard living conditions, share housing with roommates, or even move out of the community altogether. One participant described the situation, stating, “It’s a very unsettling power dynamic that exists between tenants and landlords because housing isn't available and isn't affordable and there's definitely a lot of people that are being taken advantage of.” Participants also pointed out that additional barriers, such as pet fees, further limit access to appropriate housing. Challenges in housing availability are contributing to mental health issues among residents, who often feel uncertain about their future and unsupported within the community. One participant highlighted the emotional toll of being forced to relocate, stating, “When you have to move out of the area that you're comfortable with, you lose your sense of security, your support systems, and that has a huge mental impact on oneself.” Another participant emphasized the impact on social connections, explaining that “people are less invested in, like developing strong friendships because they think either you'll be gone in three years, or I'll be gone in three years. So, what's the point?” A third participant highlighted the broader social impact, noting: “Almost everyone I know has been impacted by the availability of housing and there's a lot of people, a lot of veterans who have had to move out of the area because they're on a fixed income and they can no longer afford to live here … it is mentally draining to not only have it impact you personally, but then to be able to see so many other people continuously impacted by it as well.” These sentiments reflect a broader sense of instability and disconnection caused by the lack of stable housing options. Focus group participants also noted that limited housing availability negatively affected their physical health, as the lack of options and associated stress led to issues such as mold-related illnesses, high blood pressure, hair loss, and sleep disturbances. One participant explained, “For me, the housing availability has … caused an extreme amount of stress for me, which has definitely impacted my sleep and mental health and overall health.” These impacts are felt more acutely by specific groups, including students facing insecurity due to a lack of student housing and employees contending with inadequate and unsafe employer-provided housing. 117 In the most extreme cases, a lack of housing availability results in some individuals experiencing homelessness. A 2023 report from the U.S. Department of Housing and Urban Development indicated that Montana has experienced the second largest percentage increase in homelessness since 2007 (89%), also noting that within the same time period, Montana has the highest percent increase in the number of individuals experiencing chronic patterns of homelessness (551%).281 Chronic homelessness is generally defined as someone with a disability who has been homeless for at least 12 months.282 In Gallatin County, there are limited transitional housing options and community partners report that the shelter meets nightly capacity regularly. The local shelter operated by the Human Resource Development Council served a total of 802 individuals at the shelter for calendar year 2023 and, as of October 18, 2024, served 920 for calendar 2024 representing a significant increase, especially heading into the busiest months of November and December (K. Dicomitis, personal communications October 21, 2024). Data related to individuals experiencing homelessness often are difficult to capture given the mobile lifestyle of the population. To gauge the severity of homelessness, point-in-time counts are conducted to identify the number of people experiencing homelessness in specific areas. For Gallatin County, because the majority of the county resides in Bozeman, and also due to the dispersion of other towns and subsequent difficulty in obtaining accurate counts, Bozeman is used to estimate Gallatin County- wide estimates. As of 2019, an estimated 116 Gallatin County residents were identified as homeless. This count significantly increased after the COVID-19 pandemic began in 2020. Data collection during the pandemic was disrupted due to the potential transmission associated with conducting an in-person survey. However, 2024 data indicate that the homeless population in Gallatin County rose 252%, growing to 409 residents during the five-year period. Additionally, data provided by Bozeman-based homeless service providers showed that in the last year, homeless shelters served 90 Belgrade residents, 24 Big Sky residents, and 21 Three Forks residents.283 118 Each year, public schools are required to report the number of students experiencing homelessness, which includes “children and youth who lack a fixed, regular, and adequate nighttime residence.”284 In Gallatin County, an average of 215 students (1.6%) were reportedly experiencing homelessness between 2012 to 2023. The county-level proportion is slightly lower than statewide estimates indicating an average of 2.6% of Montana students experiencing homelessness during the 11-year period. 85 120 134 145 19221 32 36 59 104 10 4 14 57 113 0 50 100 150 200 250 300 350 400 450 2019 2021 2022 2023 2024Number of residentsYear Figure 103: Point-in-time Homeless Population by Location Slept in Gallatin County, MT from 2019 to 2024* Sheltered, Emergency Shelter Sheltered, Transitional Housing Unsheltered Source: Montana Continuum of Care Coalition Point in Time Counts *Counts were not done in 2020 due to COVID-19 0% 1% 2% 3% 4%Percent of studentsSchool year Figure 104: Percent of Kindergarten-High School Students Experiencing Homelessness by School Year in Gallatin County, MT and Statewide from 2012- 2023 Gallatin County MontanaSource: Montana Office of Public Instruction 119 WATER SUPPLY To consider water supply in Gallatin County, a general knowledge of the climate is required. Gallatin County’s water supply is dependent on a hydrological cycle with annual accumulation of high-elevation snowfall. Accumulations of snowpack between October and April recharge groundwater and provide for lower elevation stream flows that are important for agriculture operations, domestic water supply, and recreation. Precipitation levels, form of precipitation, temperature trends, and Montana water law are all considerations related to current and future availability of water. The National Oceanic and Atmospheric Administration (NOAA) has monitored annual precipitation in Gallatin County since July 1889. The long-term average 12-month total precipitation is 24.2 inches and has varied from 13.9 inches in 1918 to 33.7 inches in 1997. Figure 105 shows the 12-month total precipitation for Gallatin County between 2004 and 2023. Despite the interannual variations observed since 2004, the long-term trend for annual precipitation shows a stable trend. In years with drought conditions, increased risks exist for wildfire and associated smoke, in addition to low-flow periods for Gallatin County streams and river. Conversely, years with increased snow accumulation may result in flooding. Meteorological records across the greater Yellowstone area show that temperature has increased 2.3 °F since 1950 and is increasing by 0.35°F per decade.285 Annual temperature in the greater Yellowstone area has risen significantly when averaged across all elevations and watersheds. In the Missouri River basin of the greater Yellowstone area, the average annual temperature increased by 2.6°F between 1950 and 2018. Montana’s water law operates on the principle of "first in time, first in right," giving priority to older water rights during times of limited supply. Most significant water rights in the state were established in the late 1800s for agricultural use. Due to over-appropriation, new water rights in the Upper Missouri 25 26 24 23 25 25 29 25 22 22 28 23 23 26 26 26 21 21 24 25 0 5 10 15 20 25 30 35 40 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023Average annual precipitation (inches)Year Figure 105: Average Annual Precipitation in Inches in Gallatin County, MT from 2004 to 2023 Source: National Centers for Environmental Information, National Oceanic and Atmospheric Administration (NOAA) 120 River basin have been closed since 1993. The use of exempt wells for new subdivisions has been controversial, especially in Gallatin County, where municipal water shortages are anticipated due to rapid population growth. Recent court cases and legislative actions are addressing these issues, including potential future regulations on exempt wells. Climate change also has impacted water availability, with rising temperatures leading to more precipitation as rain instead of snow, reducing snowpack and summer stream flows. In Gallatin County, some areas have elevated nitrate levels in groundwater, and arsenic is a concern in localized regions. The county is considering regulations to reduce nitrate discharge from septic systems in impaired watersheds. Despite consistent precipitation levels over the past century, the timing and form of precipitation have shifted, exacerbating water availability challenges in the region. WATER QUALITY Water quality directly affects public health by influencing the safety of drinking water, which can prevent or contribute to the spread of waterborne diseases.286 Contaminants in water sources, such as bacteria, heavy metals, and chemicals, can lead to long-term health problems, including gastrointestinal illnesses and developmental issues.287 Ensuring access to clean water is essential for maintaining overall community health and supporting daily activities like hygiene, food preparation, and agriculture. Some areas in Gallatin County have elevated nitrate levels in groundwater (Gallatin City-County Health Department unpublished data), but generally nitrate levels are below the maximum contaminant level (MCL) for drinking water (Environmental Protection Agency level of 10mg/L). Gallatin City-County Health Department is aware of a few domestic wells that are nearing and/or exceeding the maximum contaminant level for nitrate in drinking water. Arsenic is a concern in groundwater in some localized areas within the county such as the Three Forks and West Yellowstone areas.288 Arsenic does have a maximum contaminant level established for chronic consumption (10µg/L). Presently, only wells which are regulated under the Sanitation in Subdivisions Act (76-4 Montana Code Annotated) are required to test for contaminants such as nitrate, coliform, and arsenic. This test is a one-time test required during review, with no ongoing testing requirements. The Gallatin Local Water Quality District participates in the Montana Well Educated Program through Montana State University Extension Water Quality Program which provides low-cost well testing (free kits and reduced-price analysis). There are also opportunities through other agencies such as the Gallatin Conservation District, to receive reimbursement for certain analyses. Many watersheds in Gallatin County are listed by the Department of Environmental Quality as impaired for nitrate, coliform, sediment, and temperature.289 290 291 A waterbody can become “listed” under the Clean Water Act Section 303(d) for impairment. This listing requires the designation of the Total Maximum Daily Load (TMDL) which establishes the limit of contaminants, stream flow, and temperature that the surface water can handle before impairing the uses of that surface water. Uses include primary contact recreation, agricultural, aquatic life, and drinking water. This assessment also analyzes the probable sources contributing to the impairment as well as establishing a plan to restore water quality. The total maximum daily load is only enforceable against point-source pollution, which does not include typical septic systems with a subsurface discharge component such as a drain field. The Gallatin City- 121 County Health Department is currently considering adopting local regulations to require septic systems discharging within an impaired watershed to reduce the total amount of nitrates discharged. Although precipitation levels in Gallatin County have been relatively consistent for the past 100+ years, more precipitation is coming as rain instead of snow, and the timing of snowpack runoff is occurring earlier in the year. This change results in lower groundwater levels and stream flows, which may also concentrate pollutants such as nitrates. The trend of increasing temperature in Gallatin County will result in more evaporative loss of water. Population growth in the Gallatin County is creating strains on municipal water supplies and no additional water is legally available. In January 2024, the Bozeman City Commission discussed a pending report on future municipal water needs.292 The report proposes a potential solution of piping water from Canyon Ferry Reservoir near Helena, Montana (a distance of nearly 100 miles) to meet the growth demands of Gallatin County because Canyon Ferry Reservoir storage has the only legally available water in the Upper Missouri River Basin. AIR QUALITY The human health effects of air pollution exposure are variable and depend on several factors including: pollutant type and concentration, duration of exposure, frequency of exposure, and other variables,293 and people living in socioeconomically disadvantaged areas can be disproportionately affected. The specific human health effects can include stroke, heart disease, respiratory disease, cancer, dementia,294 low birthweight,295 and various other conditions. Wildfire and its associated smoke are a common concern in Gallatin County. From 2000 to 2023 the number of days with moderateix to hazardous air quality days varied 24 days to more than 160 days, with the highest frequency of moderate to hazardous days occurring between 2008 and 2011. ix Air quality is categorized using the following definitions: good (AQI: 0-50), moderate (AQI: 51-100), unhealthy for sensitive groups (AQI: 101-150), unhealthy (AQI: 151-200), very unhealthy (AQI: 201-300), hazardous (AQI: 301+). (United States Environmental Protection Agency. About air data reports. Retrieved from: https://www.epa.gov/outdoor-air-quality-data/about-air-data-reports) 122 CONCLUSIONS: TOP STRENGTHS AND OPPORTUNITIES This community health assessment examined 40 health topics and 105 measures to gain a comprehensive understanding of health in Gallatin County. The Gallatin City-County Health Department, along with the Community Health Assessment’s Community Committee, analyzed these measures to determine both positive contributors to community health and the factors adversely affecting it. This analysis included reviewing historical data to assess trends over time, as well as comparing local measures with state and national averages. Additionally, the assessment involved examining health metrics across different subgroups within Gallatin County to identify potential disparities, when those data were available. The insights gained from this assessment will enhance our understanding of community health dynamics and guide future health initiatives. TOP STRENGTHS This community health assessment highlights a range of strengths that contribute to the overall well- being and resilience of the community. Gallatin County has a thriving economy with high income levels, high education rates, low unemployment, and community growth. The community has achieved reductions in tobacco use, particularly among youth, while maintaining low diabetes prevalence and lower mortality rates compared to state and national averages. Enhanced access to healthcare services, high youth condom use, stable medical care during COVID-19, and low vaccine-preventable disease incidence further highlight the community's robust health profile and commitment to public health. These strengths create a strong foundation for continued health improvements and strategic interventions aimed at addressing identified health needs. 010 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 Number of daysYear Figure 106: Number of Moderate to Hazardous Air Quality Days per Year in Gallatin County, MT from 2000 to 2023 Moderate Unhealthy for sensitive groups Unhealthy Very Unhealthy Hazardous Source: United States Environmental Protection Agency (EPA) 123 TOP STRENGTHS FROM HEALTH DEPARTMENT PERSPECTIVE Overall, Gallatin County is a healthy and prosperous community. The community's health is robust, performing better than both state and national averages for most indicators in this assessment where comparison data were available and most of the indicators that assessed changes over time show that community health is improving. Gallatin City-County Health Department and the Community Health Assessment’s Community Committee identified the following strengths, listed in alphabetical order, during the assessment process. • Consistent Medical Provider Visits Despite COVID-19: Data shows that the percentage of people seeing a doctor remained stable during 2020-2021, suggesting that the pandemic did not significantly disrupt regular medical care. • Decreased Tobacco and Nicotine Use: The use of electronic vapor products among high school students decreased from 51% in 2019 to 35% in 2023. The percentage of adults smoking tobacco in Gallatin, Madison, and Park Counties decreased from 13% in 2016-2017 to 10% in 2020-2021. The percentage of birth mothers who smoked during pregnancy is lower in Gallatin County compared to Montana. • High Condom Use among Youth: Among sexually active students, 87% of high school and 96% of middle school students reported using a condom during their last sexual intercourse. • Improved Access to Mental Health Providers: Gallatin County has fewer residents per mental healthcare provider compared to the U.S. average, suggesting better access to mental health services. There is also a decreasing trend, indicating improving access over time. • Low Diabetes Prevalence: The percentage of the population with diabetes in Gallatin County is lower than that in both Montana and the United States, remaining stable over time at around 5% of the population. • Low Vaccine Preventable Disease Incidence: The number of cases of vaccine preventable diseases, including varicella (Chickenpox), Hepatitis B, Pertussis, Mumps, and invasive Streptococcus pneumonia are low and are not increasing. • Lower Mortality: The age-adjusted mortality rates for almost all the leading causes of death are lower in Gallatin County compared to Montana and the United States. This includes lower rates for heart disease, cancer, unintentional injury, cerebrovascular disease, chronic lower respiratory disease, COVID-19, Parkinson’s disease, and diabetes mellitus. • Stable Medicaid Enrollment for Vulnerable Groups: Foster care and disabled adult enrollment in Medicaid have remained relatively stable, with modest increases among foster care children in 2022-2023. 124 • Stable Social Services Utilization: The percentage of the population receiving cash public assistance in Gallatin County has remained relatively stable and is consistently lower than in Montana and the United States. These strengths lay a solid foundation for ongoing health improvements and strategic interventions to address the identified health needs. TOP OPPORTUNITIES The Community Health Assessment identifies several areas for improvement in Gallatin County’s well- being and resilience. While Gallatin County is collectively a healthy and prosperous community, there are social and economic disparities that impact many subgroups, including high living costs, housing affordability issues, and barriers to healthcare access. The county faces higher suicide rates compared to national averages, increasing drug overdose deaths, and high alcohol misuse among adults and youth. Many community members, including most youth, lack sufficient physical activity, and cancer rates for prostate, breast, and melanoma are above state and national averages. Many young people face challenges related to mental health and report experiencing bullying, and there was insufficient information to assess how well individuals interpret and make meaning from health information. Addressing these issues is crucial for enhancing community health in Gallatin County. TOP OPPORTUNITIES FROM HEALTH DEPARTMENT PERSPECTIVE Gallatin City-County Health Department and the Community Health Assessment’s Community Committee identified the following opportunities, listed in alphabetical order, for community health improvement during the assessment process. • Access to Medical Care: Almost 1 in 5 adults have not seen a medical provider in the past two years. Cost, health insurance coverage limitations, and wait times were all common reasons that individuals reported for delaying medical care. Emergency department visits for individuals on Medicare were higher for American Indian and Alaska Native groups compared to their peers. • Alcohol Consumption: 51% high school students and 28% middle school students reported consuming alcohol. The percent of adults that report binge drinking increased from 11% in 2018-2019 to 22% in 2020-2021. From 2012 to 2021, 46% of vehicle fatalities occurred when the driver's blood alcohol content exceeded the legal limit. The percent of annual vehicle fatalities with driver blood alcohol content was often higher in Gallatin County compared to Montana. • Bullying in Schools: 23% high school students and 35% middle school students reported being bullied on school property. • Chronic Conditions Burden (Alzheimer’s Disease, Cancer Incidence, Cardiovascular Disease Disparities, Disabilities Disparities): Age-adjusted mortality rate for Alzheimer’s disease within Gallatin County is about 23% higher than statewide estimates. Age-adjusted cancer incidence 125 rates for prostate, breast, and melanoma are higher Gallatin County compared to both Montana and the United States. While county-level data for all race and ethnicity groups were not available, the available data indicates that the White (non-Hispanic) population has a higher cardiovascular disease mortality rate than the Hispanic population (320 per 100,000 and 207 per 100,000, respectively). The CDC also has available data on age-adjusted cardiovascular disease mortality rate disparities between sexes, indicating that 366 per 100,000 males compared to 274 per 100,000 females die due to cardiovascular disease in Gallatin County. In Gallatin County, 9.2% of residents have at least one disability, with higher prevalence among American Indian (29.0%) and Black populations (18.3%) and those 75 and older (43.7%). • Cost of Living: Community members reported that the high cost of living negatively affects community health by compromising the quality of groceries individuals can purchase, limiting access to medical services, and causing stress due to financial instability. It also strains social connections, exacerbates chronic health conditions, and disproportionately impacts students, non-English speakers, seniors, and residents of remote areas. Additionally, the percentage of the population living below the poverty line is higher for those that are Hispanic or Latino, or two or more races compared to White residents. • Drug Overdoses: Between 2003 and 2021, the drug overdose mortality rate in Gallatin County increased by over 250%. Males had more fatal overdoses, as did adults aged 25 to 44, while females and younger adults had higher rates of non-fatal overdose hospitalizations compared to other groups. • Health Insurance: In 2022, 6% of individuals reported not having health insurance. Uninsured rates were much higher for Hispanic individuals, with 17% reporting being uninsured. These data were collected before Medicaid Unwinding, and uninsured rates have increased because of that process. Between April 2023 and December 2023, the number of adults and children enrolled in Medicaid in Gallatin County decreased by 2,822. • Housing Affordability and Availability: 37% of housing units in Gallatin County are occupied by renters, which is slightly higher than Montana and the United States. Additionally, 47% of renters spend more than 30% of their household income on rental costs. The median home sale price in almost all subdivisions in Gallatin County is higher than the median price across the United States. The number of individuals sleeping in an emergency shelter, transitional housing, or reported being unhoused increased significantly from 2019 to 2023. During local focus groups, participants shared that the lack of stable housing options in the community is leading to physical and mental health issues, emotional stress from forced relocation, weakened social connections, and a sense of instability and disconnection among residents. • Mental Health: 22% of middle school students and 29% of high school students reported that their mental health was not good for most or all of the past 30 days. Data indicated 18% of individuals reported not accessing mental health services because it costs too much, and 7% of 126 individuals reported they do not know where to go to access mental health services. Locally, there is a recognized urgent need for a crisis receiving center. • Physical Activity: 72% of middle school students and 73% of high school students do not meet recommended physical activity levels. Additionally, almost 14% of adults reported not exercising in the past 30 days, with 1 in 5 adults over 65 and 1 in 4 adults aged 18-24 also not engaging in any physical activity during that period. There also are low levels of active transportation in the community, with most residents commuting to work by driving alone. Only 1% of residents reported using public transportation, 5% reported walking, and 5% utilized a taxicab, motorcycle, or bike to get to work. • Suicide: Suicide rates in Gallatin County are higher than the national average and one in five middle and high school students reported serious consideration of suicide in the past year. • Understanding Health Behaviors: There was insufficient information to assess how well Gallatin County community members interpret and make meaning from health-related information. • Water Supply: Gallatin County currently is facing water shortages due to the lack of physically and legally available water, and water shortages will worsen with future development, drought, and climate change. Water shortages will likely result in changes to Montana water law making the development of new groundwater permits more difficult, and potentially affecting property development and housing construction. Water shortages will result in increasing costs for water and will likely result in barriers to equitable access to water. Determining which of these opportunities should be prioritized for community improvement strategies is important for enhancing community health in Gallatin County. NEXT STEPS The content in this report represents a comprehensive description of health for residents in Gallatin County. The next step for this information is to move from identifying strengths and opportunities within the data, to identifying priorities for the community, to creating a plan for collective action with community partners to address those priorities. COMMUNITY HEALTH ASSESSMENT USED TO DEVELOP THE COMMUNITY HEALTH IMPROVEMENT PLAN The data from the Community Health Assessment will be used to identify priorities for collective community action in the next phase of this project. That plan for collective community action is the Community Health Improvement Plan. The Community Health Improvement Plan is a multi-year plan that uses priorities from the community health assessment data to organize collective action to address gaps and/or build momentum in ways that improve community health for the residents of Gallatin County. The Community Health Improvement Plan is created by using a set of criteria to filter the opportunities identified in the Community Health Assessment into priorities. Goals related to the 127 priorities will be identified by stakeholders and implementing partners. Then, collective action plans will be developed with specific, measurable, attainable, relevant, and time-bound objectives. The plan will describe the direction and details of what partners commit to doing, and the structure of the plan will ensure accountability and communication on progress. Community assets were researched and identified collaboratively with the Community Committee. These assets were reviewed against a set of inclusion criteria and have been identified and organized according to the components of the health model used in this community health assessment. These assets (see Appendix 6) may be leveraged during the implementation of the Community Health Improvement Plan. Annual Community Health Improvement Plan updates will be used for documenting successes, challenges, progress, and anticipated next steps. EVOLUTION OF COMMUNITY HEALTH ASSESSMENT, INCLUDING POSSIBLE FUTURE DATA COLLECTIONS BASED ON FINDINGS The depth and breadth of information represented in this assessment is important for the Gallatin City- County Health Department to understand the comprehensive picture of health for residents in its jurisdiction. The information also is useful for community partners as they understand the community context, make decisions about programming and services, and direct efforts and resources for future activities. Community members may also find the information about health in Gallatin County to be useful to their understanding for personal action or grassroots efforts. Because many stakeholders at many levels will use this information, the Gallatin City-County Health Department will make intentional efforts to distribute this comprehensive report as well as condensed, less technical formats for partners and the public. The concept of a Community Health Assessment is not static. Rather, the health of the community can continue to evolve and can be understood with future data activities. After this Community Health Assessment report and project are finalized, it is anticipated that follow-up data collection activities will take place with an evolving set of representatives from organizations and populations in the community. These future activities may investigate gaps or explore other areas of inquiry identified as the report is disseminated and studied by community partners. Possible known gaps and areas for future exploration that arose during the report writing are listed in Appendix 2. As the discussions of future data activities unfold, the make-up of the Community Committee will be considered as adaptable to reflect the areas of further exploration to ensure a continuing eye toward diversity, equity, and representation of a wide variety of groups and populations is included. 128 APPENDICES 129 APPENDIX 1: LEADING CAUSES OF DEATH The following tables provide a summary of leading causes of death, first by race/ethnicity and then by age group. Table 3: Leading Causes of Death by Race/Ethnicity in Gallatin County, MT 2012-2023 Rank All Races White, non- Hispanic Black, non-Hispanic Asian/Pacific Islander American Indian/ Alaska Native Hispanic 1 Heart disease Heart disease Accidents Suicide Malignant neoplasms Malignant neoplasms 2 Malignant neoplasms Malignant neoplasms Heart disease Heart disease -Accidents -Heart disease Heart disease 3 Accidents Accidents -Certain conditions originating in the perinatal period -Malignant neoplasms -Nephritis, nephrotic syndrome, and nephrosis Accidents Accidents 4 Cerebrovascular diseases Cerebrovascular diseases Cerebrovascular diseases Suicide -Chronic liver disease and cirrhosis -Diabetes mellitus 5 Chronic lower respiratory diseases Chronic lower respiratory diseases -In situ neoplasms, benign neoplasms, and neoplasms of uncertain or unknown behavior -Malignant neoplasms -Nephritis, nephrotic syndrome, and nephrosis Chronic lower respiratory diseases 6 Suicide Suicide -Anemias -COVID-19 -Chronic lower respiratory diseases -Diabetes mellitus -In situ neoplasms, benign neoplasms, and neoplasms of uncertain or unknown behavior -Suicide Diabetes mellitus -Cerebrovascular diseases -Certain conditions originating in the perinatal period -Suicide 7 Alzheimer’s disease Alzheimer’s disease -Alzheimer’s disease -Chronic liver disease and cirrhosis -Influenza and pneumonia 8 COVID-19 COVID-19 -Certain conditions originating in the perinatal period -Chronic lower respiratory diseases -COVID-19 -Influenza and pneumonia -Homicide -Septicemia 9 -Influenza and pneumonia -Parkinson’s disease Parkinson’s disease COVID-19 10 Influenza and pneumonia -Cerebrovascular diseases -COVID-19 -Nephritis, nephrotic syndrome, and nephrosis -Septicemia -Alzheimer’s disease -Chronic lower respiratory diseases -Congenital malformation, deformations, and chromosomal abnormalities -Homicide -Influenza and pneumonia -Nephritis, nephrotic syndrome, and nephrosis -Pneumonitis due to solids and liquids 130 Source: Vital Statistics Analysis Unit, Montana Department of Public Health and Human Services Notes: Causes of death listed under the same rank indicate the same number of deaths. There were low death counts for the leading causes of death for non- White ethnicities as the ranking went lower (with counts of 3 or fewer death occurrences). 131 Table 4: Leading Causes of Death by Age Group in Gallatin County, MT 2012-2023 Rank All Ages 1-14 Years 15-24 Years 25-44 Years 45-64 Years 65+ Years 1 Heart disease Accidents Suicide Accidents Malignant neoplasms Heart disease 2 Malignant neoplasms Certain conditions originating in the perinatal period Accidents Suicide Heart disease Malignant neoplasms 3 Accidents Congenital malformations, deformations, and chromosomal abnormalities Certain conditions originating in the perinatal period Malignant neoplasms Accidents Cerebrovascular diseases 4 Cerebrovascular diseases Suicide Heart disease Heart disease Suicide Chronic lower respiratory diseases 5 Chronic lower respiratory diseases -Homicide -Influenza and pneumonia -Malignant neoplasms -Homicide -Malignant neoplasms Chronic liver disease and cirrhosis Chronic liver disease and cirrhosis Alzheimer’s disease 6 Suicide Homicide Chronic lower respiratory diseases Accidents 7 Alzheimer’s disease -Chronic lower respiratory diseases -Congenital malformations, deformations, and chromosomal abnormalities -Diabetes mellitus -Septicemia Cerebrovascular diseases COVID-19 COVID-19 8 COVID-19 -Acute bronchitis and bronchiolitis -Heart disease Influenza and pneumonia Diabetes mellitus Parkinson’s disease 9 -Influenza and pneumonia -Parkinson’s disease -Diabetes mellitus -Legal intervention Cerebrovascular diseases Influenza and pneumonia 10 N/A Nephritis, nephrotic syndrome, and nephrosis Diabetes mellitus Source: Vital Statistics Analysis Unit, Montana Department of Public Health and Human Services Notes: Causes of death listed under the same rank indicate the same number of deaths. Some of the leading causes of death with lower ranks for 25-44 years could have a death count of 5 or fewer, while most of the leading causes of death for 1-14 years and 15-24 years have death counts of 3 or fewer. 132 APPENDIX 2: KNOWN GAPS / AREAS FOR FUTURE EXPLORATION There are many additional topics which could be explored in the future to gain additional perspective on health in Gallatin County. The following topics are organized according to the community health assessment health model. COMMUNITY CONTEXT Within the community context section of the report, the main gap in data exists within health literacy. While several national surveys are aimed at capturing data to either directly or indirectly (via modelling projections) measure health literacy, no local data specifically regarding health literacy was identified. This highlights an opportunity to intentionally capture and continue to track progress in metrics related to health literacy among Gallatin County residents. MORBIDITY Morbidity refers to a broad area of public health which encompasses any factors contributing to poor health. Due to the comprehensive range of factors contributing to morbidity, it was necessary to prioritize certain metrics over others for inclusion within the report. Due to the small size of many subpopulations within Gallatin County, data exploring differences in morbidity rates between specific subgroups (e.g., specific races, ethnicities, or age groups) was sparse but included where possible. This proves to be a consistent gap across most counties in Montana due to smaller populations but should be prioritized and explored further as the data allows and/or becomes available. MORTALITY As stated in the above morbidity section, the small sample sizes of many subpopulations within Gallatin County made it difficult to explore differences between mortality rates among various subgroups (e.g., specific races, ethnicities, or age groups). This proves to be a consistent gap across most counties in Montana due to smaller populations but should be prioritized and explored further as the data allows and/or becomes available. HEALTH BEHAVIORS There are many aspects of community interactions, healthy eating, substance use, how individuals understand health behaviors, and physical activity that were not explored in this community health assessment. These unexplored areas include community interaction measures about relationships and social capital, routines, the impact of seasons on interactions, and community tension; substance use measures of driving under the influence (DUI) arrests, and excessive caffeine use; healthy eating measures of quality of food and food waste; understanding of health behavior measures such as media consumption, dehydration, handwashing, and lifelong health education; and physical activity measures of time spent outdoors, types of exercises performed, seasonal impact on behaviors, and access to exercise opportunities and outdoor places. These omissions were due to gaps in secondary data and capacity constraints, highlighting potential areas for future research and exploration. 133 The Community Committee also recognized the significance of prevention of sun exposure in influencing the health of Gallatin County; however, this factor was not prioritized for inclusion in this assessment as the impact on health and the community's ability to address it were perceived to be lower compared to other factors. Nonetheless, this area remains a potential area for future exploration. There are many other behaviors that impact individual and community health that were not included in this community health assessment, such as child and adolescent development, injury prevention, safe food handling, and violence prevention.296 While existing secondary data is available for most of these topics in Gallatin County, these were not included in this community health assessment because they were not selected by the community committee. These remain potential areas for future exploration. Finally, most of the indicators analyzed for this report were only available at the county level, so demographic or geographic subgroup differences were not assessed. Understanding the differences between subgroups is another potential area for future exploration. ACCESS TO SERVICES There are many aspects of influences to access, cost of services, and social services which were not explored in this community health assessment. These unexplored areas include affordability of specific types of services, community awareness of financial assistance programs or insurance, benefits use, burden of emergency costs, case management practices, eligibility for support programs, number of providers that accept Medicaid, physical location of healthcare providers, impact of language barriers on service access, impact of policies on access to services, social perception of mental health, impact of stigmas for certain groups or behaviors, and information about specialty providers. These omissions were due to gaps in secondary data and capacity constraints, highlighting potential areas for future research and exploration. The Community Committee also recognized the significance of provider and specialist availability, insurance navigation, and physical access to services in influencing the health of Gallatin County; however, these factors were not prioritized for inclusion in this assessment as their impact on health and the community's ability to address them were perceived to be lower compared to other factors. Nonetheless, these areas remain potential areas for future exploration. There are many other factors associated with access to services that impact individual and community health that were not included in this community health assessment, such as access to family planning services, access to prescription medications, access to prevention-focused screenings, and access to medical records.297 While existing secondary data may have been available for most of these topics in Gallatin County, these were not included in this community health assessment because they were not selected by the community committee. These remain potential areas for future exploration. Finally, most of the indicators analyzed for this report were only available at the county level, so demographic or geographic subgroup differences were not assessed. Understanding the differences between subgroups is another potential area for future exploration. 134 SOCIAL AND ECONOMIC FACTORS There are many aspects of housing affordability, cost of living, and employment that were not explored in this community health assessment. These unexplored areas include if individuals have been displaced, employer absence data, hours spent working, number of jobs individuals have, psychological safety, quality and affordability of food, time usage data, workforce harassment, and injury complaints. These omissions were due to gaps in secondary data and capacity constraints, highlighting potential areas for future research and exploration. The Community Committee also recognized the significance of inclusive practices, community safety, adverse childhood experiences, and culture and perception of mental health in influencing the health of Gallatin County; however, these factors were not prioritized for inclusion in this assessment as their impacts on health and the community's ability to address them were perceived to be lower compared to other factors. Nonetheless, these areas remain potential areas for future exploration. Finally, most of the indicators analyzed for this report were only available at the county level, so demographic or geographic subgroup differences were not assessed. Understanding the differences between subgroups is another potential area for future exploration. ENVIRONMENTAL FACTORS There are many aspects of transportation, housing quality, housing availability, water support, water quality, and air quality that were not explored in this community health assessment. These unexplored areas include access to and use of public transportation, distances traveled to access various resources, helmet use, impact of the climate on physical activity, pedestrian safety, road safety, and commute times. These omissions were due to gaps in secondary data and capacity constraints, highlighting potential areas for future research and exploration. The Community Committee also recognized the significance of wildfire impacts, access to nature, climate change, walkability, and access to community spaces in influencing the health of Gallatin County; however, these factors were not prioritized for inclusion in this assessment as their impacts on health and the community's ability to address them were perceived to be lower compared to other factors. Nonetheless, these areas remain potential areas for future exploration. There are many other factors associated with the environment that impact individual and community health that were not included in this community health assessment, such as information about neighborhoods and the built environment.298 While existing secondary data is available for most of these topics in Gallatin County, these were not included in this community health assessment because they were not selected by the community committee. These remain potential areas for future exploration. Finally, most of the indicators analyzed for this report were only available at the county level, so demographic or geographic subgroup differences were not assessed. Understanding the differences between subgroups is another potential area for future exploration. 135 APPENDIX 3: ADDITIONAL METHODS DISCUSSION The following content provides additional information about the key components that were developed, and the methods used in the assessment project. MODEL DESIGN AND DEFINITIONS During the Community Committee model co-creation meeting, and as part of the ranking form related to Creating the Health Model, the Core Group provided the definitions for each of the health factor themes as well as a set of guiding questions to facilitate the conversation and activity. The purpose of providing the definitions and guiding questions was to establish a common foundation for the Community Committee during the working session. The guiding questions provided to the Community Committee were as follows: 1. What [health behaviors, access to services factors, social and economic factors, and environmental factors] have the most influence on the health of Gallatin County? 2. What [health behaviors, access to services factors, social and economic factors, and environmental factors] do we as a community have an ability to impact in Gallatin County? 3. What should we be measuring to understand [health behaviors, access to services factors, social and economic factors, and environmental factors] in Gallatin County? Table 5 outlines the definitions provided to the Community Committee during the model development process (sourced from the Public Health Accreditation Board glossary299 or the County Health Rankings model300). Table 5: Community Health Assessment Health Model Term Definitions Core Health Model Terms Definition Health The Public Health Accreditation Board draws on the World Health Organization definition of health as follows: Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Demographics The Public Health Accreditation Board defines demographics as follows: Demographics are characteristic related data, such as size, growth, density, distribution, and vital statistics, which are used to study human populations. Health Outcomes County Health Rankings defines health outcomes as how long people live on average within a community, and how much physical and mental health people experience in a community while they are alive. Length of Life The time between birth and death is defined as length of life. We measure how long people live to reveal what might have led to early deaths. We investigate length of life among population groups to help us understand differences in health outcomes. 136 Core Health Model Terms Definition Quality of Life Quality of life represents the well-being of a community, underscoring the importance of physical, mental, social, and emotional health from birth to adulthood. Health Factors Many things influence how well and how long we live. Health factors represent those things we can improve to live longer and healthier lives. They are indicators of the future health of our communities. Health Behaviors Health behaviors are health-related practices, such as diet and exercise, that can improve or damage the health of individuals or community members. Health behaviors are determined by the choices available in the places where people live, learn, work, and play. Access to Services [Access to services / Clinical Care] is anything relating to the direct medical treatment or testing of patients. Access to affordable, quality health care can prevent disease and lead to earlier disease detection. Communities are living longer lives because of breakthroughs in clinical care, such as advancements in vaccinations, surgical procedures, and preventative screenings. Social and Economic Factors Social and Economic Factors affect how well and how long we live. Social and economic factors include factors such as income, education, employment, community safety, and social support. The choices that are available in a community are impacted by social and economic factors. These choices include our abilities to afford medical care and housing and to manage stress. Environment The physical environment is where individuals live, learn, work, and play. People interact with their physical environment through the air they breathe, the water they drink, the homes in which they live, and the transportation they use. Table 6 below outlines the assessment health model categories, themes, topics, and definitions. Table 6: Health Model Categories, Themes, Topics, and Definitions Category Theme Topic Definition Community Profile Demographics Total population The number of people living in Gallatin County, including citizens and noncitizens per the U.S. Census. Urban/rural The percentage of the total population living in rural and urban areas The U.S. Census defines rural as anywhere outside of an urban area. Urban is defined as an area encompassing at least 2,000 housing units or have a population of at least 5,000.301 302 137 Category Theme Topic Definition Age The number of males and females broken out by 5-year age categories. Sex/gender An individual's biological status as male, female, or something else. Sex is assigned at birth and associated with physical attributes, such as anatomy and chromosomes. Race/ethnicity How people self-identify based on racial, ethnic, and national origins and sociocultural groups. It is recognized that the categories of the race item include racial and national origin or sociocultural groups. People may choose to report more than one race to indicate their racial mixture. Racial categories include White, Black/African American, Asian, American Indian/Alaska Native, Native Hawaiian Other Pacific Islander, or Some Other Race. Ethnicity is characterized as Hispanic/Latino or non- Hispanic/Latino.303 Languages spoken The predominant language that people speak at home. Immigration status People who live in Gallatin County and Montana who were not born in the United States.304 Community Context Education Education is acquiring knowledge and skills within a formal learning environment. This is inclusive of the United States public education system, from elementary school through college and university systems. Employment Employment is the exchange of time and labor for monetary compensation.305 The common expectation is that, depending on household size, individuals should be able to balance the income generated and the cost of daily living in a community when 138 Category Theme Topic Definition employed in one local, full-time job. Employment provides income that can support healthy lifestyle choices.306 Income Income is dollars earned by the exchange of labor through employment and/or dollars earned through investments. Poverty occurs when the amount of income is insufficient to cover certain cost of living standards. The U.S. government’s poverty level for a family of four was $30,000 in 2023.307 Housing A housing unit is a house, an apartment, a mobile home, a group of rooms, or a single room that is occupied (or if vacant, is intended for occupancy) as separate living quarters.308 309 Projected growth rate Changes in the population of a defined geographic area over time. Environment The external components that make up a place. The environment includes natural factors such as air, climate, water, and natural surroundings, but also includes the human-made or built environment. Health literacy The degree to which individuals have the ability to find, understand, and use information and services to inform health- related decisions and actions for themselves and others. Similar to a health behavior: Health literacy allows individuals have more autonomy in impacting their own health.310 Health Outcomes Length of Life Mortality The age-adjusted deaths per 100,000 persons per year. Infant mortality Deaths per 1,000 live births per year. Life expectancy Life expectancy is defined as the average number of years a group of persons are expected to survive from a given starting age.311 139 Category Theme Topic Definition Suicide Death caused by self-directed means with the intent to die as a result. Injury/violence-related Deaths from external forces like from accidents or other unintentional means as well as deaths caused by other humans. Quality of Life Adult health status A characterization of health status based on self-reported number of days (over the past month) where physical health is not good. Chronic conditions Diagnosed medical conditions that last one year or more and require ongoing medical attention and/or limit daily activities.312 Communicable disease Infectious diseases are illnesses caused by germs (such as bacteria, viruses, and fungi) that enter the body, multiply, and can cause an infection. Some infectious diseases are contagious (or communicable), meaning they are capable of spreading from one person to another. Other infectious diseases can be spread by germs carried in air, water, food, or soil. They can also be spread by vectors (like biting insects) or by animals to humans.313 Mental health Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act, and helps determine how we handle stress, relate to others, and make choices.314 Maternal child health Maternal Child Health is a public health sub-field that began by focusing on a specific population (mothers and children), rather than a method (as with epidemiology) or skillset (as with health policy).315 Health Factors Health Behaviors Community interaction Community interaction is the interplay of influences that enable 140 Category Theme Topic Definition or prevent individuals and families in a community to interact in positive and supportive ways across the lifespan. These influences are related to social relationships and connection, place-based factors, and individual habits and skills. Substance use Substance use refers to the use of illegal drugs and inappropriate use of legal substances (e.g. alcohol and tobacco) that can lead to possible dependence and other negative health outcomes.316 Understanding health behaviors Understanding health behaviors refers to how individuals interpret and make meaning from health- related information. By understanding how behavior influences health, individuals have more autonomy to impact their own health. The quality of that information can have unintended future consequences on an individual’s health behaviors. Healthy eating Healthy eating is the practice of consuming a variety of nutritionally-balanced foods and drinks in recommended amounts and distributions. Healthy eating is impacted by the availability, cost, quality of food in an area, and a variety of other community and individual factors.317 Physical activity Physical activity is moving one’s body by exerting physical effort in line with recommended duration and movement type. Physical activity is done over the lifespan, and is impacted by seasons, access to safe spaces, and knowledge of recommendations, benefits, and applications. Access to Services Influences to access Influences to access are the positive facilitators and the negative barriers to individuals 141 Category Theme Topic Definition accessing a diverse range of health- related programs and services in their community. These influences range from linguistic access and current policy landscape to perceptions, stigma, inclusivity, cost, insurance coverage, and transportation. Access to mental health services Access to mental health services is an individual’s ability to reach local programs and care providers that are relevant, available, affordable, and accessible for the spectrum of mental health needs, including programs for managing mental health, programs to provide acute and crisis care, and in-patient and out-patient services. Cost of services Cost of services is the financial burden individuals experience to receive the health care and health- related programs that they need and require, and which are available in the community. Access to social services Access to social services is an individual’s ability to reach local federally-funded/subsidized social services (such as Medicaid, Supplemental Nutrition Assistance Program (SNAP) and Women, Infants, and Children (WIC)) for which they are eligible. Access includes an individual’s awareness of programs and adequate service provider participation in such programs. Social and Economic Factors Housing affordability Housing affordability is the ability to buy or rent a reasonable, safe place to live that does not impose disproportionate financial burden or inhibit the pursuit of other nondiscretionary spending and reasonable financial goals. Typically, housing is affordable if housing cost does not exceed 30 percent of income.318 Severe 142 Category Theme Topic Definition housing burden is when more than 50 percent of income is spent on housing costs.319 Cost of living Cost of living is the financial resources needed for maintaining a certain standard of daily living in a location. Cost of living includes both the real cost of daily living expenses and the wages needed to support such expenses.320 Environmental Factors Housing availability Housing availability is the presence of safe, stable, and secure housing units on the market for purchase or rent at an affordable price. (see housing affordability definition) Transportation/commuting Transportation is the infrastructure and mechanisms in a community that move individuals from one place to another whether through active transportation (walking, biking) or by public or personal vehicle. The expectation is that transportation can happen in a way that is safe and accessible for the individual, community, and environment. Commuting specifically refers to a worker’s travel from home to work.321 Housing quality Housing quality refers to the physical characteristics and comparative standard of materials, age, and durability of housing units in a community. Poor housing conditions, such as the presence of lead, mold, or asbestos, poor air quality, and overcrowding, can contribute to negative health outcomes.322 Water supply Water supply is the current and future availability of adequate, clean, safe, and affordable water for individuals in a community. Water supply can be impacted by 143 Category Theme Topic Definition factors such as population growth, climate change, and pollution. COMMUNITY COMMITTEE MEMBER LIST At the outset of the Community Health Assessment process, a group of representatives from a range of organizations was convened to form the Community Committee. The Community Committee was intentionally designed to bring a diverse set of community perspectives to the project, representing organizations active across the social determinants of health domains. The organizations that comprise the Community Committee as well as a brief description of the sector they represented is summarized in the table below. Table 7: Community Committee Members by Organization and Sector Represented Organization Sector Representation Bozeman Health Non-profit, Non-government, Local healthcare system Bozeman Public Schools Local public education Bridgercare Non-profit, Non-government, Represents populations who have lived experiences with or are disproportionately affected by conditions that contribute to health outcomes, represent populations experiencing or have expertise addressing inequities Child Care Connections Non-profit, Non-government, Represents populations experiencing or have expertise addressing inequities City of Belgrade Local government City of Bozeman Local government Community Health Partners Non-profit, Non-government, Local healthcare system, Represents populations experiencing or have expertise addressing inequities, Represents populations who have lived experiences with or are disproportionately affected by conditions that contribute to poorer health outcomes, local public education, rural community Family Promise Non-profit, Non-government, Represents populations experiencing or have expertise addressing inequities, Represents populations who have lived experiences with or are disproportionately affected by conditions that contribute to poorer health outcomes Gallatin City- County Board of Health Local government Gallatin City- County Health Department Local government Gallatin County Sheriff’s Office Local government Gallatin Valley Land Trust Non-government, non-profit 144 Organization Sector Representation Greater Gallatin United Way Non-profit, Non-government, Represents populations experiencing or have expertise addressing inequities, Represents populations who have lived experiences with or are disproportionately affected by conditions that contribute to poorer health outcomes Haven Non-profit, Non-government, Represents populations who have lived experiences with or are disproportionately affected by conditions that contribute to poorer health outcomes Human Resource Development Council Non-profit, Non-government, Represents populations experiencing or have experience addressing inequities, Represents populations who have lived experiences or are disproportionately affected by conditions that contribute to poorer health outcomes, Local public education, Rural community Montana Language Services Non-profit, Non-government, Represents populations experiencing or have expertise addressing inequities Montana State University Public higher education Providence Mental Health Non-profit, Non-government, Local healthcare system, Represents populations experiencing or have expertise addressing inequities, Represents populations who have lived experiences with or are disproportionately affected by conditions that contribute to poorer health outcomes Thrive Non-government, Non-profit, Represents populations experiencing or have expertise addressing inequities, Local public education Veterans’ Affairs Government, Local healthcare system, Represents populations experiencing or have expertise addressing inequities, Represents populations who have lived experiences with or are disproportionately affected by conditions that contribute to poorer health outcomes, Rural community Wellness in Action Non-government, Non-profit, Local healthcare system, Represents populations experiencing or have expertise addressing inequities, Rural community, Represents populations who have lived experiences with or are disproportionately affected by conditions that contribute to poorer health outcomes West Yellowstone Government, Represents populations experiencing or have expertise addressing inequities, Represents populations who have lived experiences with or are disproportionately affected by conditions that contribute to poorer health outcomes, Rural community 145 COMMUNITY COMMITTEE ENGAGEMENT The following timeline is a summary of the Community Committee engagement during the development of the Community Health Assessment. The activities listed at the top are the phases of the project. The star icon indicates an in-person Community Committee meeting or workshop. Other activities were asynchronous. 146 ACKNOWLEDGING THE USE OF CHAT GPT As artificial intelligence tools emerge, we are learning about their utility and limitations. It is important to acknowledge when and how such tools are used when producing information available to the public. For this community health assessment, tools such as Chat GPT were used minimally. The use of Chat GPT was limited to a few applications. Chat GPT was used to simplify a couple of sections of text, such as simplifying the technical information regarding legal and physical availability of water, transferring the key takeaway messages from bullet points into narrative, and a few other such small instances. In any application of the tool, the text was reworded to ensure proper syntax, flow, and use within the report. 147 APPENDIX 4: FOCUS GROUP DISCUSSION AND KEY INFORMANT INTERVIEWS Focus group discussions were used to generate data related to the health model topics of cost of living and housing affordability as they relate to health. While there were data available about cost of living and housing affordability, the explicit connection to their impact on health was not clear based on existing datasets. In order to understand these relationships, the Core Group designed and implemented three focus group discussion sessions to better understand how cost of living and housing affordability impact the health of residents of Gallatin County. RECRUITMENT PROCESS Each focus group discussion session was capped at 16 participants. Recruitment was open to any resident of Gallatin County aged 18 years or older. Recruitment efforts included the following strategies: • In-person events, such as the Manhattan Public School Employee Wellness Fair (March 15, 2024) • Printed fliers in public spaces, such as the Belgrade Public Library, Bozeman Public Library community board, Bozeman Community Co-op community board, local coffee shops, local food bank, local grocery stores, and local senior centers • Social media posts from the health department, the Gallatin County accounts, the Belgrade Public Library accounts, and others • Promotion through internal and external newsletters • Promotion through local news coverage • Promotion through adjacent relevant local coalition • Content shared with Community Committee members to broadcast content to their networks The focus group discussion session schedules were designed with accessibility in mind. A range of times and days of the week were considered so that individuals with work commitments, family obligations, or limited ability to travel could find an option that might work for their circumstances. These considerations are outlined in the table below, organized by focus group discussion session. Table 8: Focus Group Discussion Recruitment Strategies Region/Location Access Strategy Bozeman Tuesday, April 9, 2024 12:00pm – 1:30pm Bozeman Public Library Cottonwood Room Lunch-time meeting, in-person Allows folks working in Bozeman (whether residents of Bozeman, Belgrade, or elsewhere) to participate over the lunch hour when they might already have availability and proximity to the meeting space Food provided Belgrade Thursday, April 11, 2024 Evening meeting, in-person Allows folks who cannot join over the lunch hour and who live in the area to participate 148 Region/Location Access Strategy 6:00pm – 7:30pm Belgrade Public Library Milesnick Meeting Room Food provided Manhattan, Three Forks, West Yellowstone, other Saturday, April 13, 2024 10:00am – 11:30am Teams link (sent following registration) Weekend meeting, online Allows folks who work and cannot get childcare to attend from anywhere in Gallatin County PARTICIPANT REGISTRATION The recruited participants registered using an online registration form. The participants registered up to 24 hours before the event. This timeline was intended to allow for final details to be prepared ahead of the events (such as food and materials). When a participant registered, they were asked for food allergy information. Following the registration submission, a confirmation email was sent to the participant, as well as a reminder email sent the day prior to the event. DISCUSSION AND INTERVIEW PROTOCOLS The design of the focus group discussion was to build the discussion from general to specific questions relating to cost of living, housing availability, and their impact on health. In advance of asking any questions, some common framing was established with the participants. The framing discussion included an overview of the project, how the model and its topics were developed, and how the key terms are defined (health, health factors, cost of living, and housing availability). Participants were introduced to the intent of using the information, as well as an affirmation that all information offered during the discussion session was valid. The aim was to have a total of approximately 5-10 questions in the final interview protocol (not including probing and follow-up questions). The following table outlines the questions, sequence, and intent of each question. Table 9: Focus Group Discussion Protocol Number Question Type Question Wording Question Rationale 1.1 General, Framing When you think of health, what comes to mind? Initiates conversation Establishes use of definitions Broad, introductory question to get people 1.2 Think back to a time you have felt healthy, describe some of what contributed to that feeling. 149 Number Question Type Question Wording Question Rationale talking and thinking about the overarching topics 2.1 Core Think back over the past year or two. What are some of the factors in your life that have influenced your health? Starts to bring conversation to participants’ personal experience of health and what impacts their health 2.2 Thinking back again over the past year or two, what choices or compromises have you made because of cost of living? In general? Related to your health? Starts to make the explicit connection between health (as we define it) and cost of living (as we define it) and how housing availability impacts / has a role to play in an individual’s health 2.3 Thinking back again over the past year or two, what choices or compromises have you made because of housing availability? In general? Related to your health? Starts to make the connection between health (as we define it) and housing availability (as we define it) and how housing availability impacts / has a role to play in an individual’s health 2.4 What comes to mind when I say the words cost of living in relation to health? Asks participants to provide specific examples of the relationship between cost of living and health 2.5 What comes to mind when I say the words housing availability in relation to health? Asks participants to provide specific examples of the relationship between housing availability and health 2.6 Suppose you were describing how cost of living impacts your health to a friend. What would you say? Asks participants to describe the interplay of cost of living and health in their own words / experience 2.7 Suppose you were describing how housing availability impacts your health to a friend. What would you say? Asks participants to describe the interplay of housing availability and 150 Number Question Type Question Wording Question Rationale health in their own words / experience 2.8 Are there specific groups or populations you think have been disproportionately impacted by recent changes in Gallatin County’s cost of living/housing availability? Asks participants to reflect on possible areas of disparity within the community 3.1 Summary Of all the things we’ve talked about, what to you is most important? Asks participants to identify the most pressing aspects of these topics 3.2 Have we missed anything we should talk about today? Offers an opportunity for participants to contribute something that might not have yet been considered APPENDIX 5: DATA BIOGRAPHY AND INCLUSION CRITERIA The key data sources used within this report are described below. A data biography detailing all sources used within the report is available upon request. Table 10: Data Biography Source Description Behavioral Risk Factor Surveillance System (BRFSS) BRFSS is a cross-sectional phone-based survey conducted annually throughout the United States since 1984. It is co-managed by the Centers for Disease Control and Prevention (CDC) and the Montana Department of Public Health and Human Services (MTDPHHS). BRFSS collects prevalence data regarding health-related risk behaviors, chronic health conditions, and the use of preventive services among U.S. adults. In addition to health status and behaviors, demographic information – like age, sex, and race – is gathered in order to evaluate differences between various subgroups of the population. Unless noted otherwise, BRFSS prevalence estimates are weighted based on gender by age group, race/ethnicity, education, marital status, tenure, gender by race/ethnicity, age group by race/ethnicity, and phone ownership status. Montana Infectious Disease Information System (MIDIS) Montana statutes require the reporting of conditions and communicable diseases of public health significance to local and state public health authorities. MIDIS is a nationally developed application for the secure receipt and storage of information submitted to local and state public health authorities. The system contains records for all communicable diseases reportable in the state of Montana. Data are only accessible to select local and state public health staff who conduct case investigations and manage records. Limited case information is also transmitted to the CDC for further analysis. MIDIS includes information detailing diagnosis and laboratory testing, geographic and demographic information, and details related to case 151 Source Description investigations, including risk factors/behaviors for HIV, sexually transmitted infections, and approximately 70 other reportable conditions. National Center for Health Statistics (NCHS) As part of the Centers for Disease Control and Prevention (CDC), NCHS provides statistical information and data insights into the health of people across the United States. The data review topics such as births, deaths, medical records, and laboratory testing, among others. Datasets are available publicly online and are primarily updated annually, but several datasets are updated on a more frequent basis. United States Census: American Community Survey (ACS) The U.S. Census Bureau launched the ACS in 2005 and continues to utilize it annually to collect vital information about the nation and its people. The ACS covers a broad range of topics related to social, economic, demographic, and housing characteristics of the U.S. population. The 5-year estimates from the ACS are “period” estimates that represent data collected over a period of time. The primary advantage of using multiyear estimates is the increased statistical reliability of the data for less populated areas and small population subgroups. United States Census: Decennial Census Every 10 years since 1790, the U.S. census counts each resident of the United States and which state they live in. The process is mandated by the Constitution and helps to determine how to allocate the House of Representatives among each of the states. Every household in the county receives an invitation to respond to a short survey provided either online, by phone, or by mail. The data collection for the state and local finance survey is comprised of three modes to obtain data: mail canvass, internet collection, and central collection from state sources. Collection methods vary by state and type of government. Vital Statistics Vital statistics data are nationally required reportable conditions which consist of six vital events: live births, deaths, fetal deaths, induced abortions, marriages, and divorces. Records also include identifying information, demographic data, and relevant medical information. Local and state departments collect and manage data related to their own residents, which then get shared with CDC’s NCHS. If a vital event occurs in a different state or country, it is counted based on state residency. Youth Risk Behavior Surveillance System (YRBSS) YRBSS is a set of surveys administered biannually to students in middle schools (grades 7-8), high schools, and non-public accredited/alternative high schools. It is co-managed by the CDC and the Montana Office of Public Instruction (OPI) and has been used to collect youth-related data throughout the United States since 1988. Data are self-reported by students and are used to measure health- related behaviors and experiences which have the potential to cause disability or death among youth and adults. Similar to BRFSS, YRBSS also collects demographic data – like age, sex, race/ethnicity – in order to evaluate differences between subgroups of the population. County-level data do not consider any variable weights or adjustments. 152 DESCRIPTION OF STATISTICS The techniques described below were used throughout many of the data analyses and summaries included in this assessment. • Data suppression: Based on guidelines set by the Montana Department of Public Health and Human Services, counts of fewer than five events (<5) are suppressed to maintain confidentiality and rates for fewer than 20 (<20) events are suppressed due to unreliability.323 Suppressed data points within the report are indicated using the † symbol. • Age-adjustment: Age-adjustments are used to allow researchers to compare health outcomes among populations consisting of different age groups. This is done because most diseases or health outcomes occur at different rates in different age groups. For example, most chronic conditions, like cancers or cardiovascular disease, occur more often among older age groups; other outcomes, like unintentional injury, occur more often among younger age groups. Age- adjustments are computed using the direct method and proportions based on the 2000 U.S. standard population. • Rate per 100,000: Calculating the occurrence of diseases or health outcomes per 100,000 residents allows researchers to compare rates between two or more populations of different sizes. Rates are calculated by dividing the number of events by the subgroup’s population size (e.g. males, ages <18, or Hispanic/Latino) and multiplying by 100,000. DATA INCLUSION CRITERIA Prior to secondary data collection, several inclusion criteria were selected to assist with identifying consistent and appropriate data sources to utilize in the report. Table 11: Data Inclusion Criteria Category Specific Criteria Effective 1. Availability of high-quality data that are population-based (where possible), measurable, accurate, and reliable. Data should focus on rates rather than counts. 2. Ability to make valid comparisons to a baseline or benchmark. 3. Ability to describe data collection methods in a data biography. Feasible 4. Data already collected, analyzed, and/or reported. 5. Analysis of secondary data is feasible if it can be conducted in the equivalent of three working days. Important 6. Potential to drive improvement in health, social drivers of well-being, and/or equity. 7. Potential to develop new knowledge about what creates well-being. 8. Captures a high-level view of the topic area. Usable and Useful 9. Availability of data that is regularly updated on a frequency between one day and five years. Priority will be given to more timely data if it meets the other criteria. 153 Category Specific Criteria 10. Ability to examine the data by at least one of the following breakdowns: age, gender, race/ethnicity, geography, income or education, sexual orientation, and/or language. (Not all breakdowns may be available for all indicators.) 11. Useful to communities, subject matter experts, and/or stakeholders. 154 APPENDIX 6: COMMUNITY ASSET LIST The Community Asset List provides an overview of relevant resources in the community that could be leveraged or mobilized to address community health and well-being. For this community health assessment, the Core Group created inclusion criteria that would be used to evaluate whether assets from the community were relevant to the assessment process. The criteria included whether the asset was currently operating and serving Gallatin County, whether it was accessible to underserved or at-risk populations, and whether the asset’s services fit into the scope of the 10 Essential Public Health Services,324 the social determinants of health,325 and the Foundational Public Health Services.326 After creating the criteria, an asset list generated in 2020 was used as the starting point. Assets known to have formed since 2020 were added and additional assets were researched. Several groups were asked for input to the list. These groups included all health department staff, the Core Group, and the Community Committee. As assets were identified, they were screened against the criteria and organized according to the health model used in this community health assessment. Toward the end of the asset identification and categorization process, the list of community assets was sent to the Community Committee for a final review to verify the way assets were categorized and to identify any assets that were either missing or no longer relevant. HEALTH OUTCOMES: LENGTH OF LIFE MORTALITY • Big Sky Palliative and Hospice • Bozeman Health • Bozeman Health Behavioral Health • Bozeman Health Cancer Center • Bozeman Health Cardiology • Bozeman Health Geriatric Medicine • Bozeman Health Hospice Services • Bozeman Health Nutrition Services • Bozeman Health Palliative Care • Bozeman Health Pediatrics • Bozeman Health Pulmonology • Bozeman Health Women's Specialists • Bozeman Police Department • Gallatin County Sheriff’s Office • Hebgen Basin Fire District • Life Flight Air Ambulance INFANT MORTALITY • Bozeman Health • Bozeman Health Pediatrics • Bozeman Health Women's Specialists • Bozeman Police Department • Healthy Mothers, Healthy Babies (Montana Coalition) • Hebgen Basin Fire District • Roots Family Collaborative 155 PREMATURE MORTALITY • ASPEN (Abuse Support & Prevention Education Network) • Bozeman Health • Bozeman Health Behavioral Health • Bozeman Health Cancer Center • Bozeman Health Cardiology • Bozeman Health Geriatric Medicine • Bozeman Health Hospice Services • Bozeman Health Palliative Care • Bozeman Health Pediatrics • Bozeman Health Pulmonology • Bozeman Health Women's Specialists • Bozeman Help Center • Bozeman Mobile Crisis Response Team • Bozeman Police Department • Bozeman VA Clinic • Charlie Health • Connections Health Solutions • Energy Share • Gallatin County Emergency Management • Gallatin County Sheriff’s Office • Gallatin Mental Health Services • Haven • Hebgen Basin Fire District • HRDC • HRDC Energy Assistance • Ideal Option • Life Flight Air Ambulance • Montana Fish, Wildlife & Parks: Hunter and Trapper Education • Montana Fish, Wildlife & Parks: Pollution Control • MSU Campus Civil Rights • MSU Counseling and Psychological Services (MSU-CPS) • MSU Insight (Alcohol and Drug Assistance Center) • NAMI • Prime for Life • SNAP • Suffer Out Loud • The Warming Center/ Drop in Center • Western Montana Mental Health Center SUICIDE • Bozeman Health • Bozeman Health Behavioral Health • Bozeman Health Cancer Center • Bozeman Health Cardiology • Bozeman Health Geriatric Medicine • Bozeman Health Hospice Services • Bozeman Health Nutrition Services • Bozeman Health Palliative Care • Bozeman Health Pediatrics • Bozeman Health Pulmonology • Bozeman Health Women's Specialists • Bozeman Help Center • Bozeman Mobile Crisis Response Team • Bozeman Police Department • Bozeman VA Clinic • Charlie Health • Connections Health Solutions • Gallatin Mental Health Services • Montana 211 • MSU Counseling and Psychological Services (MSU-CPS) • NAMI 156 • Suffer Out Loud • Western Montana Mental Health Center INJURY / VIOLENCE • Adult Protective Services • ASPEN (Abuse Support & Prevention Education Network) • B2 Urgentcare Big Sky • Big Sky Medical Center • Billings Clinic (in Bozeman) • Billings Clinic (in West Yellowstone) • Billings Clinic Pediatrics (in Bozeman) • Bozeman Fire and Central Valley Fire District • Bozeman Health • Bozeman Health Geriatric Medicine • Bozeman Health Pediatrics • Bozeman Help Center • Bozeman Police Department • Charlie Health • Chiropractic Clinic of Three Forks • City of Belgrade • City of Bozeman • City of Three Forks • Community Health Partners • Connections Health Solutions • Gallatin County Emergency Management • Gallatin County Planning & Community Development • Gallatin County Sheriff’s Office • Gallatin County Victim Services Program • Haven • Hearts & Homes Family Resource Center • Hebgen Basin Fire District • HRDC Energy Assistance • Life Flight Air Ambulance • Montana 211 • Montana Department of Child and Family Services • Montana Fish, Wildlife & Parks: Hunter and Trapper Education • Mountain Pearls Dentistry • MSU Campus Civil Rights • Town of Manhattan • Town of West Yellowstone • West Yellowstone Dental HEALTH OUTCOMES: QUALITY OF LIFE ADULT HEALTH STATUS • Billings Clinic (in Bozeman) • Billings Clinic (in West Yellowstone) • Board of Health • Bozeman Health • Bozeman Health Behavioral Health • Bozeman Health Cancer Center • Bozeman Health Cardiology • Bozeman Health Geriatric Medicine • Bozeman Health Hospice Services • Bozeman Health Palliative Care 157 • Bozeman Health Pulmonology • Bozeman Health Women's Specialists • City of Belgrade • City of Bozeman • City of Three Forks • Gallatin City-County Health Department • Montana Primary Care Association • Montana State University • MSU Student Health • SAMHSA • Three Rivers Medical Clinic • Town of Manhattan • Town of West Yellowstone CHRONIC CONDITIONS • Ability Montana • AIDS Outreach • AWARE Inc. • Belgrade Senior Center • Big Sky Medical Center • Big Sky Palliative and Hospice • Big Sky School District • Billings Clinic (in Bozeman) • Billings Clinic (in West Yellowstone) • Billings Clinic Pediatrics (in Bozeman) • Board of Health • Bozeman Creek Family Health • Bozeman Health • Bozeman Health Behavioral Health • Bozeman Health Cancer Center • Bozeman Health Cardiology • Bozeman Health Geriatric Medicine • Bozeman Health Hospice Services • Bozeman Health Nutrition Services • Bozeman Health Palliative Care • Bozeman Health Pediatrics • Bozeman Health Pulmonology • Bozeman Public Schools • Bozeman Senior Center • Bozeman VA Clinic • Bridger Children's Dentistry • Bridgercare • Cancer Support Community Montana • Chiropractic Clinic of Three Forks • Community Health Partners • Disability Rights Montana • Eagle Mount • Family Outreach Inc. • Gallatin City-County Health Department • Gallatin County Council on Aging • LiveNOW! / ActNOW! • Manhattan School District • Medicaid • Montana 211 • Montana Alzheimer's Association • Montana Asthma Home Visiting Program • Montana State University • Montana Vocational Rehab • Mountain Pearls Dentistry • MSU Extension's Living Well with Dementia and Mobile Memory Cafe • MSU Proyecto Salud • MSU Student Health • nCenter • Qualicare Home Care • Reach Inc. • SHIP and Medicare • SNAP • Spring Creek Inn • Three Forks School District • Three Rivers Medical Clinic • West Yellowstone Dental 158 • West Yellowstone School • West Yellowstone Senior Center COMMUNICABLE DISEASE • AIDS Outreach • Big Sky Medical Center • Billings Clinic (in Bozeman) • Billings Clinic (in West Yellowstone) • Billings Clinic Pediatrics (in Bozeman) • Board of Health • Bozeman Creek Family Health • Bozeman Health • Bozeman Health Pediatrics • Bozeman Health Pulmonology • Bozeman Health Women's Specialists • Bozeman VA Clinic • Bridgercare • Community Health Partners • Gallatin City-County Health Department • Medicaid • Montana 211 • Montana State University • MSU Health Advancement (MSU- HA) • MSU Student Health • SHIP and Medicare • Three Rivers Medical Clinic • ZoeCare MENTAL HEALTH • 406 Recovery • Ability Montana • Advocacy Center in the Law and Justice Center • AIDS Outreach • AWARE Inc. • Befrienders • Belgrade Alliance Church: Celebrate Recovery • Belgrade School District • Big Brothers Big Sisters • Big Sky Medical Center • Big Sky School District • Bozeman Creek Family Health • Bozeman Health Behavioral Health • Bozeman Health Geriatric Medicine • Bozeman Health Palliative Care • Bozeman Health Pediatrics • Bozeman Health Women's Specialists • Bozeman Help Center • Bozeman Mobile Crisis Response Team • Bozeman Public Schools • Bozeman Therapy & Counseling, LLC • Bozeman VA Clinic • Bridger Peaks Counseling • Bridger Psychiatric Services • Cancer Support Community Montana • Charlie Health • Connections Health Solutions • Disability Rights Montana • Eating Disorder Center of Montana • Gallatin Behavioral Health Coalition • Gallatin Detention Center • Gallatin Mental Health Services • Greater Gallatin United Way • Haven • HRDC • HRDC Head Start • HRDC Senior Services • Little Bear Counseling 159 • Love Inc. • Manhattan School District • Mental Health Local Advisory Council • Montana 211 • Montana State University • MSU Campus Recreation (MSU-CR) • MSU Counseling and Psychological Services (MSU-CPS) • MSU Health Advancement (MSU- HA) • MSU Human Development Clinic • NAMI • nCenter • Providence Mental Health Services • Psychiatry Associates • Roots Family Collaborative • SAMHSA • Suffer Out Loud • Three Forks School District • Trans Closet • Treatment Court • Wellness in Action • West Yellowstone School • Western Montana Mental Health Center • Yellowstone Boys and Girls Ranch MATERNAL, CHILD HEALTH • AWARE Inc. • Belgrade School District • Big Brothers Big Sisters • Big Sky School District • Big Sky Youth Empowerment • Billings Clinic (in Bozeman) • Billings Clinic (in West Yellowstone) • Billings Clinic Pediatrics (in Bozeman) • Board of Health • Bozeman Creek Family Health • Bozeman Health • Bozeman Health Nutrition Services • Bozeman Health Pediatrics • Bozeman Health Women's Specialists • Bozeman Public Schools • Bridger Children's Dentistry • Bridgercare • Cancer Support Community Montana • Charlie Health • Community Health Partners • Cover Montana • Family Outreach Inc. • Family Promise of Gallatin Valley • Fork & Spoon • Gallatin City-County Health Department • Gallatin County Victim Services Program • Gallatin Mental Health Services • Gallatin Valley Farm to School • Gallatin Valley Food Bank • Greater Gallatin United Way • Healthy Montana Kids (HMK)/ Transportation Assistance • Healthy Mothers, Healthy Babies (Montana Coalition) • Hearts & Homes Family Resource Center • HRDC • HRDC Energy Assistance • HRDC Head Start • HRDC Healthy KidsPack • Manhattan School District • Medicaid • Montana 211 • Montana Asthma Home Visiting Program 160 • Montana Department of Child and Family Services • Montana Food Bank Network: West Yellowstone Food Bank • MSU Health Advancement (MSU- HA) • MSU Human Development Clinic • Parents as Teachers • Pride House (406) • Roots Family Collaborative • Salvation Army • Smiles Across Montana • Three Forks School District • Three Rivers Medical Clinic • Thrive • West Yellowstone Recreation Program • West Yellowstone School • West Yellowstone Social Services • WIC • Yellowstone Boys and Girls Ranch • YMCA • ZoeCare HEALTH FACTORS: HEALTH BEHAVIORS COMMUNITY INTERACTION • AARP Bozeman • Ability Montana • AIDS Outreach • American Indian Hall • AWARE Inc. • Befrienders • Belgrade Alliance Church: Celebrate Recovery • Belgrade School District • Belgrade Senior Center • Bienvendidos at Gallatin Valley • Big Brothers Big Sisters • Big Sky Food Bank and Resource Center • Big Sky School District • Big Sky Youth Empowerment • Billings Clinic (in Bozeman) • Billings Clinic (in West Yellowstone) • Billings Clinic Pediatrics (in Bozeman) • Bozeman and Belgrade Senior Centers Meals on Wheels • Bozeman Creek Family Health • Bozeman Health • Bozeman Health Behavioral Health • Bozeman Health Cancer Center • Bozeman Health Cardiology • Bozeman Health Geriatric Medicine • Bozeman Health Hospice Services • Bozeman Health Nutrition Services • Bozeman Health Palliative Care • Bozeman Health Pediatrics • Bozeman Health Pulmonology • Bozeman Health Women's Specialists • Bozeman Help Center • Bozeman Public Library • Bozeman Public Schools • Bozeman Senior Center • Bozeman Tenants United • Bozeman Therapy & Counseling, LLC • Bridger Peaks Counseling • Cancer Support Community Montana • Career Transitions • Charlie Health • City of Belgrade • City of Bozeman 161 • City of Three Forks • Community Health Partners • Disability Rights Montana • Eagle Mount • Family Outreach Inc. • Farmers Markets • Fork & Spoon • Gallatin Behavioral Health Coalition • Gallatin City-County Health Department • Gallatin County Council on Aging • Gallatin County Victim Services Program • Gallatin Detention Center • Gallatin Empires Lions Club • Gallatin Mental Health Services • Gallatin Refugee Connections • Gallatin Valley Farm to School • Gallatin Valley Food Bank • Gallatin Valley Land Trust • Greater Gallatin United Way • Greater Impact • Haven • Healthy Mothers, Healthy Babies (Montana Coalition) • Hearts & Homes Family Resource Center • HRDC • HRDC Head Start • HRDC Healthy KidsPack • HRDC Senior Services • Imperial Sovereign Court of the State of Montana • Jean Nedrud (Gallatin County Tenant Advocate) • Little Bear Counseling • Manhattan School District • Montana 211 • Montana Alzheimer's Association • Montana Department of Child and Family Services • Montana Fair Housing • Montana Language Services • Montana Legal Services • Montana State University • Montana Vocational Rehab • MSU Campus Civil Rights • MSU Campus Recreation (MSU-CR) • MSU Counseling and Psychological Services (MSU-CPS) • MSU Extension's Living Well with Dementia and Mobile Memory Cafe • MSU Health Advancement (MSU- HA) • MSU Human Development Clinic • MSU Insight (Alcohol and Drug Assistance Center) • MSU Proyecto Salud • MSU Towne's Harvest Garden • NAMI • Parents as Teachers • Pride House (406) • Prime for Life • Qualicare Home Care • Queer Bozeman • Reach Inc. • Roots Family Collaborative • Sacks Thrift Stores • Salvation Army • SMART Recovery • Smiles Across Montana • Spring Creek Inn • Three Forks School District • Thrive • Town of Manhattan • Town of West Yellowstone • Trans Closet • Treatment Court • West Yellowstone Recreation Program • West Yellowstone School • West Yellowstone Senior Center 162 • Western Montana Mental Health Center • World Languages Imitative • Yellowstone Boys and Girls Ranch • Yellowstone Club Community Foundation • YMCA SUBSTANCE USE • 406 Recovery • Belgrade Alliance Church: Celebrate Recovery • Big Sky Medical Center • Billings Clinic (in Bozeman) • Board of Health • Bozeman Public Schools • Bozeman VA Clinic • Bridger Peaks Counseling • Charlie Health • Community Medical Services • Gallatin Behavioral Health Coalition • Gallatin City-County Health Department • Gallatin Detention Center • Greater Impact • Ideal Option • Manhattan School District • Montana 211 • MSU Counseling and Psychological Services (MSU-CPS) • MSU Health Advancement (MSU- HA) • MSU Insight (Alcohol and Drug Assistance Center) • Prime for Life • SAMHSA • SMART Recovery • Tobacco Quit Line • Treatment Court • Western Montana Mental Health Center HEALTHY EATING • Belgrade Alliance Church: Celebrate Recovery • Belgrade Senior Center • Big Brothers Big Sisters • Big Sky Food Bank and Resource Center • Billings Clinic (in Bozeman) • Bozeman and Belgrade Senior Centers Meals on Wheels • Bozeman Health Nutrition Services • Bozeman Senior Center • Career Transitions • Community Gardens • Community Health Partners • Eating Disorder Center of Montana • Farmers Markets • Gallatin City-County Health Department • Gallatin County Council on Aging • Gallatin Valley Farm to School • Gallatin Valley Food Bank • Headwaters Food Bank • HRDC • HRDC Head Start • HRDC Healthy KidsPack • HRDC Senior Services • LiveNOW! / ActNOW! • Love Inc. • Montana 211 • Montana Food Bank Network: West Yellowstone Food Bank • MSU Bounty of the Bridgers 163 • MSU Counseling and Psychological Services (MSU-CPS) • MSU Health Advancement (MSU- HA) • nCenter • Office of Public Assistance • Office of Public Assistance Bozeman: Montana Food Bank Network • Salt & Light Food & Care Pantry • Salvation Army • SNAP • Spring Creek Inn • Three Forks School District • West Yellowstone Senior Center • West Yellowstone Social Services • WIC • YMCA PHYSICAL ACTIVITY • AWARE Inc. • Belgrade Senior Center • Big Brothers Big Sisters • Big Sky Youth Empowerment • Billings Clinic (in Bozeman) • Bozeman Health Nutrition Services • Bozeman Health Pulmonology • Bozeman Senior Center • Cancer Support Community Montana • Chiropractic Clinic of Three Forks • Community Gardens • Community Health Partners • Eagle Mount • Gallatin City-County Health Department • Gallatin County Council on Aging • Gallatin Empires Lions Club • Gallatin Valley Land Trust • LiveNOW! / ActNOW! • Montana 211 • MSU Campus Recreation (MSU-CR) • Queer Bozeman • SNAP • West Yellowstone Recreation Program • YMCA UNDERSTANDING HEALTH BEHAVIORS • AARP Bozeman • Ability Montana • AWARE Inc. • Belgrade Alliance Church: Celebrate Recovery • Belgrade School District • Big Brothers Big Sisters • Big Sky Medical Center • Big Sky School District • Big Sky Youth Empowerment • Billings Clinic (in Bozeman) • Billings Clinic (in West Yellowstone) • Bozeman Health • Bozeman Health Behavioral Health • Bozeman Health Cancer Center • Bozeman Health Cardiology • Bozeman Health Geriatric Medicine • Bozeman Health Hospice Services • Bozeman Health Nutrition Services • Bozeman Health Palliative Care • Bozeman Health Pulmonology • Bozeman Health Women's Specialists • Cancer Support Community Montana • Community Health Partners 164 • Eating Disorder Center of Montana • Family Outreach Inc. • Gallatin City-County Health Department • Gallatin County Council on Aging • Gallatin Valley Farm to School • Greater Impact • HRDC • HRDC Head Start • LiveNOW! / ActNOW! • Montana 211 • Montana Alzheimer's Association • Montana Asthma Home Visiting Program • MSU Extension's Living Well with Dementia and Mobile Memory Cafe • MSU Health Advancement (MSU- HA) • MSU Insight (Alcohol and Drug Assistance Center) • MSU Proyecto Salud • MSU Student Health • Parents as Teachers • Prime for Life • SMART Recovery • Smiles Across Montana • SNAP • Tobacco Quit Line • YMCA HEALTH FACTORS: ACCESS TO SERVICES INFLUENCES TO ACCESS • Ability Montana • ASPEN (Abuse Support & Prevention Education Network) • AWARE Inc. • Befrienders • Big Brothers Big Sisters • Big Sky Palliative and Hospice • Big Sky Youth Empowerment • Billings Clinic Pediatrics (in Bozeman) • Bozeman and Belgrade Senior Centers Meals on Wheels • Bozeman Health • Bozeman Health Behavioral Health • Bozeman Health Cancer Center • Bozeman Health Cardiology • Bozeman Health Geriatric Medicine • Bozeman Health Hospice Services • Bozeman Health Nutrition Services • Bozeman Health Palliative Care • Bozeman Health Pulmonology • Bozeman Health Women's Specialists • Bozeman Public Library • Bozeman Tenants United • Cancer Support Community Montana • City of Belgrade • City of Bozeman • City of Three Forks • Community Health Partners • Disability Rights Montana • Eagle Mount • Eating Disorder Center of Montana • Family Outreach Inc. • Fork & Spoon • Gallatin Behavioral Health Coalition • Gallatin City-County Health Department • Gallatin Empires Lions Club • Gallatin Refugee Connections • Gallatin Valley Farm to School • Greater Gallatin United Way • Healthy Montana Kids (HMK)/ 165 Transportation Assistance • HRDC • HRDC Head Start • Ideal Option • LIHEAP (Low Income Home Energy Assistance Program) • Montana Asthma Home Visiting Program • Montana Food Bank Network: West Yellowstone Food Bank • Montana Language Services • Montana Legal Services • Montana Primary Care Association • Montana State University • Montana Unemployment Insurance • MSU Bounty of the Bridgers • MSU Extension's Living Well with Dementia and Mobile Memory Cafe • MSU Health Advancement (MSU- HA) • MSU Proyecto Salud • NAMI • Office of Public Assistance • Office of Public Assistance Bozeman: Montana Food Bank Network • Pride House (406) • Qualicare Home Care • Rocky's Agency on Aging • Salvation Army • SMART Recovery • Smiles Across Montana • SNAP • Spring Creek Inn • State of Montana Dental Cost Assistance Program • Suffer Out Loud • Tobacco Quit Line • Town of Manhattan • Town of West Yellowstone • Trans Closet • Treatment Court • VASH Program • Wellness in Action • West Yellowstone Recreation Program • West Yellowstone Senior Center • West Yellowstone Social Services • WIC • ZoeCare ACCESS TO MENTAL HEALTH SERVICES • 406 Recovery • AWARE Inc. • B2 Urgentcare Big Sky • Belgrade School District • Big Sky School District • Bozeman Health • Bozeman Health Behavioral Health • Bozeman Health Cancer Center • Bozeman Health Cardiology • Bozeman Health Geriatric Medicine • Bozeman Health Hospice Services • Bozeman Health Nutrition Services • Bozeman Health Palliative Care • Bozeman Health Pulmonology • Bozeman Health Women's Specialists • Bozeman Mobile Crisis Response Team • Bozeman Public Schools • Bozeman Therapy & Counseling, LLC • Bridger Peaks Counseling • Cancer Support Community Montana • Connections Health Solutions 166 • Gallatin Mental Health Services • Haven • HRDC Senior Services • Manhattan School District • Mental Health Local Advisory Council • MSU Health Advancement (MSU- HA) • NAMI • Pride House (406) • Providence Mental Health Services • Suffer Out Loud • Three Forks School District • Treatment Court • Wellness in Action • West Yellowstone School • Western Montana Mental Health Center • Yellowstone Boys and Girls Ranch • ZoeCare ACCESS TO SOCIAL SERVICES • AARP Bozeman • ASPEN (Abuse Support & Prevention Education Network) • City of Belgrade • City of Bozeman • City of Three Forks • Cover Montana • Gallatin City-County Health Department • Gallatin Refugee Connections • HRDC Senior Services • Medicaid • Montanaworks.gov (Bozeman Job Service) • MSU Health Advancement (MSU- HA) • Office of Public Assistance • Office of Public Assistance Bozeman: Montana Food Bank Network • Rocky's Agency on Aging • SHIP and Medicare • SNAP • State of Montana Dental Cost Assistance Program • Town of Manhattan • Town of West Yellowstone • usa.gov • West Yellowstone Social Services COST OF SERVICES • AIDS Outreach • AWARE Inc. • Big Brothers Big Sisters • Big Sky Youth Empowerment • Bozeman Health • Bridgercare • Energy Share • Fork & Spoon • Gallatin City-County Health Department • Gallatin Empires Lions Club • Greater Gallatin United Way • Habitat for Humanity • Healthy Montana Kids (HMK)/ Transportation Assistance • HRDC • HRDC Energy Assistance • HRDC Homeless Prevention • Ideal Option • LIHEAP (Low Income Home Energy Assistance Program) • Medicaid • Montana Asthma Home Visiting Program • Montana Legal Services • MSU Bounty of the Bridgers • MSU Health Advancement (MSU- HA) 167 • MSU Proyecto Salud • Office of Public Assistance Bozeman: Montana Food Bank Network • Pride House (406) • Prime for Life • SHIP and Medicare • State of Montana Dental Cost Assistance Program • Suffer Out Loud • Tobacco Quit Line • Wellness in Action • WIC • Yellowstone Boys and Girls Ranch • ZoeCare HEALTH FACTORS: SOCIAL AND ECONOMIC FACTORS HOUSING AFFORDABILITY • AWARE Inc. • Bozeman Tenants United • Family Promise of Gallatin Valley • Gallatin County Planning & Community Development • Gallatin Mental Health Services • HRDC • HRDC Emergency Rental Assistance • HRDC Home Ownership Center • HRDC Homeless Prevention • HRDC Section 8/ Housing Choice Voucher Program • HRDC Seeking Housing Services • LIHEAP (Low Income Home Energy Assistance Program) • Montana 211 • MSU Health Advancement (MSU- HA) • Office of Public Assistance • Reach Inc. • Regional Housing Coalition • Resource Property Management (RPM) • Rocky's Agency on Aging • VASH Program • West Yellowstone Recreation Program COST OF LIVING • ASPEN (Abuse Support & Prevention Education Network) • Belgrade Senior Center • Greater Gallatin United Way • Habitat for Humanity • HRDC • HRDC Emergency Rental Assistance • HRDC Energy Assistance • HRDC Healthy KidsPack • HRDC Home Ownership Center • HRDC Homeless Prevention • HRDC Section 8/ Housing Choice Voucher Program • HRDC Seeking Housing Services • LIHEAP (Low Income Home Energy Assistance Program) • Montana Legal Services • Pride House (406) • Resource Property Management (RPM) • Sacks Thrift Stores • Salt & Light Food & Care Pantry • Salvation Army • SNAP • Streamline Bus 168 EMPLOYMENT • AARP Bozeman • ASPEN (Abuse Support & Prevention Education Network) • Bozeman Job Service/Montana Works • City of Belgrade • City of Bozeman • City of Three Forks • Family Outreach Inc. • Family Promise of Gallatin Valley • Gallatin Detention Center • Gallatin Mental Health Services • HRDC • Montana 211 • Montana Unemployment Insurance • Montana Vocational Rehab • Montanaworks.gov (Bozeman Job Service) • Reach Inc. • Town of Manhattan • Town of West Yellowstone • West Yellowstone Social Services HEALTH FACTORS: ENVIRONMENTAL FACTORS HOUSING AVAILABILITY • Bozeman Tenants United • City of Belgrade • City of Bozeman • City of Three Forks • Family Promise of Gallatin Valley • Gallatin County Planning & Community Development • Habitat for Humanity • Haven • HRDC • HRDC Home Ownership Center • MSU Health Advancement (MSU- HA) • Reach Inc. • Regional Housing Coalition • Resource Property Management (RPM) • Rocky's Agency on Aging • Spring Creek Inn • The Warming Center/ Drop in Center • Town of Manhattan • Town of West Yellowstone • West Yellowstone Recreation Program HOUSING QUALITY • Board of Health • Bozeman Fire and Central Valley Fire District • Bozeman Tenants United • City of Belgrade • City of Bozeman • City of Three Forks • Energy Share • Gallatin City-County Health Department • Gallatin County Planning & Community Development • Habitat for Humanity • Haven • HRDC • HRDC Energy Assistance • Jean Nedrud (Gallatin County Tenant Advocate) • Montana Fair Housing • Montana Legal Services • Regional Housing Coalition • Rocky's Agency on Aging 169 • Town of Manhattan • Town of West Yellowstone WATER SUPPLY • Advocacy Center in the Law and Justice Center • Board of Health • City of Belgrade • City of Bozeman • City of Three Forks • Gallatin City-County Health Department • Gallatin County Planning & Community Development • Gallatin Local Water District • Gallatin Valley Land Trust • LIHEAP (Low Income Home Energy Assistance Program) • Montana Department of Environmental Quality, Water Quality District • Montana Department of Fish, Wildlife & Parks (Pollution Control) • Town of Manhattan • Town of West Yellowstone TRANSPORTATION • City of Belgrade • City of Bozeman • Galavan • Gallatin County Council on Aging • Healthy Montana Kids (HMK)/ Transportation Assistance • HRDC • HRDC Senior Services • Life Flight Air Ambulance • Montana 211 • MSU Health Advancement (MSU- HA) • MSU Western Transportation Institute • Qualicare Home Care • Reach Inc. • Skyline, Link to the Peak • Spring Creek Inn • Streamline Bus • West Yellowstone Foundation 170 APPENDIX 7: LIST OF ACRONYMS, FIGURES, AND TABLES The following are lists of acronyms, figures, and tables in the report above. LIST OF ACRONYMS CDC ................................. U.S. Centers for Disease Control and Prevention HIV/ AIDS ........................ Human Immunodeficiency Virus / Acquired Immunodeficiency Syndrome SNAP ............................... Supplemental Nutrition Assistance Program U.S. ................................. United States of America WIC ................................. Women, Infants, and Children LIST OF FIGURES Figure 1: Gallatin County Community Health Assessment Health Model Figure 2: Social Determinants of Health Figure 3: Population of Gallatin County, MT by Age and Sex in 2018-2022 Figure 4: Percent of Population Living in Urban and Rural Areas in Gallatin County, MT in 2010 and 2020 Figure 5: Percent of Population by Ethnicity in Gallatin County, MT in 2010 and 2020 Figure 6: Percent of non-Hispanic Population by Race in Gallatin County, MT in 2010 and 2020 Figure 7: Languages Spoken at Home by Percent of Population in Gallatin County, MT in 2018-2022 Figure 8: Languages Spoken at Home by Percent of non-English-speakers in Gallatin County, MT in 2018- 2022 Figure 9: Place of Birth and Citizenship Status among Residents in Gallatin County, MT in 2018-2022 Figure 10: Educational Attainment among Adults Aged 25+ Years in Gallatin County, MT, Statewide, and the United States in 2018-2022 Figure 11: Middle through High School Drop-out Rate by School Year in Gallatin County, MT and Statewide from 2014 to 2023 Figure 12: Top Five Largest Job Industries in Gallatin County, MT as of 2023 Figure 13: Annual Unemployment Rate over Time in Gallatin County, MT, Statewide, and the United States from 2000 to 2023 Figure 14: Labor Force Participation Rate among Adults Aged 20-64 Years by Sex and Child Status in Gallatin County, MT from 2015 to 2022 171 Figure 15: Median Annual Household Income in Gallatin County, MT, Statewide, and the United States from 2013 to 2022 Figure 16: Percent of Population below the Poverty Line by Age Group, Sex, and Race in Gallatin County, MT, Statewide, and the United States in 2022 Figure 17: Value of Owner-occupied Units* in Gallatin County, MT, Statewide, and the United States in 2018-2022 Figure 18: Number of Licensed Tourist Homes Registered per Year in Gallatin County, MT, from 2017 to 2024* Figure 19: Population over Time in Gallatin County, MT from 2013 to 2022 Figure 20: Percent Change in Population in Gallatin County, MT and Statewide from 2013 to 2022 Figure 21: Population Growth Projections through 2040 in Gallatin County, MT Figure 22: Percent of Adults Self-reporting Physically Unhealthy Days in the Past Month Gallatin, Madison, and Park Counties, MT from 2016 to 2021 Figure 23: Percent of Adults Ages 18 Years or Older Self-reporting Poor or Fair Health Status in Gallatin, Madison, and Park Counties, MT from 2016 to 2021 Figure 24: Percent of Population with a Disability by Age Group, Race/Ethnicity, Gender, and Overall in Gallatin County, MT as of 2022 Figure 25: Percent of Population by Disability Type in Gallatin County, MT from 2015 to 2022 Figure 26: Age-adjusted Incidence Rate of All Cancer Sites per 100,000 Population in Gallatin County, MT, Statewide, and the United States in 2016-2020 Figure 27: Age-adjusted Cancer Incidence Rates per 100,000 Population in Gallatin County, MT, Statewide, and the United States in 2016-2020 Figure 28: Age-adjusted Obesity Prevalence among Adults in Gallatin County, MT, Statewide, and the United States in 2011 and 2021 Figure 29: Age-adjusted Diabetes Prevalence among Adults in Gallatin County, MT, Statewide, and the United States from 2011 to 2021 Figure 30: Monthly COVID-19 Hospitalizations in Gallatin County, MT from March 2020 to July 2024 Figure 31: Monthly COVID-19 Cases in Gallatin County, MT from March 2020 to July 2024 172 Figure 32: Proportion of Population and COVID-19 Cases, Hospitalizations, and Deaths by Age Group in Gallatin County, MT from March 2020 to July 2024 Figure 33: Seasonal Influenza Case Rate per 100,000 Population in Gallatin County, MT from 2013 to 2024 Figure 34: Seasonal Influenza Hospitalization Rate per 100,000 Population in Gallatin County, MT from 2013 to 2024 Figure 35: Sexually Transmitted Infection Incidence in Gallatin County, MT from 2018 to 2023 Figure 36: Chlamydia and Gonorrhea Cases by Age Group in Gallatin County, MT in 2018-2023 Figure 37: Vaccine Preventable Disease Incidence in Gallatin County, MT from 2014 to 2023 Figure 38: Percent of Bozeman Help Center Calls by Most Type in Gallatin County, MT from 2012 to 2022 Figure 39: Percent of Adults Reporting 14+ Mentally Unhealthy Days in the Past Month in Gallatin, Madison, and Park Counties, MT from 2016 to 2021 Figure 40: Mental Health Indicators among Surveyed Middle and High School Students in Gallatin County, MT from 2017 to 2023 Figure 41: Percent of Surveyed Students Reporting Poor Mental Health during Most or All of the Past Month in Gallatin County, MT in 2021 and 2023 Figure 42: Prevalence of Adverse Prenatal Outcome Indicators in Gallatin County, MT and Statewide in 2014-2018 Figure 43: Percent of Births to Mothers Who Smoked during Pregnancy in Gallatin County, MT, Statewide, and the United States from 2019 to 2022 Figure 44: Leading Causes of Mortality with Age-adjusted Rates per 100,000 Population in Gallatin County, MT, Statewide, and the United States in 2018-2022 Figure 45: Years of Potential Life Lost before Age 75 for Leading Causes of Mortality in Gallatin County, MT in 2018-2022 Figure 46: Age-adjusted Cardiovascular Disease Mortality Rate per 100,000 Population by Race/Ethnicity, Gender, and Location, Gallatin County, MT in 2019-2021 Figure 47: Infant Mortality Rate per 1,000 Live Births in Gallatin County, MT, Statewide, and the United States in 2013-2022 Figure 48: Annual Maternal and Late Maternal Deaths in Montana from 2006-2022 Figure 49: Birth Rate per 1,000 Population in Gallatin County, MT, Statewide, and the United States from 2016 to 2021 173 Figure 50: Age-adjusted Suicide Rate per 100,000 Population in Gallatin County, MT, Statewide, and the United States from 2016 to 2022 Figure 51: Suicide Indicators among Surveyed High School Students in Gallatin County, MT from 2017 to 2023 Figure 52: Suicide Indicators among Surveyed Middle School Students in Gallatin County, MT, from 2017 to 2023 Figure 53: Unintentional Injury Mortality Rates per 100,000 Population in Gallatin County, MT, Statewide, and the United States in 2018-2022 Figure 54: Crude Drug Overdose Death Rate per 100,000 Population in Gallatin County, MT from 2003 to 2021 Figure 55: Number of Fatal Drug Overdoses by Age Group and Sex in Gallatin County, MT in 2009-2023 Figure 56: Percent of Fatal Overdoses by Drug Type in Gallatin County, MT in 2009-2023 Figure 57: Annual Number of Vehicle-related Fatalities in Gallatin County, MT from 2003 to 2022 Figure 58: Percent of Vehicle-related Fatalities by Vehicle Type* in Gallatin County, MT in 2003-2022 Figure 59: Percent of Vehicle Fatalities with Driver Blood Alcohol Content Greater Than or Equal to 0.08 in Gallatin County, MT, Statewide, and the United States from 2003 to 2022 Figure 60: Intentional Injury Mortality Rate per 100,000 Population in Gallatin County, MT, Statewide, and the United States in 2018-2022 Figure 61: Percent of Adults Aged 65+ Living Alone in Gallatin County, MT, Statewide, and the United States from 2013 to 2022 Figure 62: Percent of Surveyed Students Reporting Being Bullied/Teased in Gallatin County, MT from 2017 to 2023 Figure 63: Percent of Surveyed Students Spending 3+ Hours per Day on Screen Time (excluding Schoolwork) in Gallatin County, MT in 2021 and 2023 Figure 64: Percent of Surveyed Students Using Social Media at Least Daily in Gallatin County, MT in 2023 Figure 65: Percent of Surveyed Middle School Students Indicating Substance Use in Gallatin County, MT from 2017 to 2023 Figure 66: Percent of Surveyed High School Students Indicating Substance Use in Gallatin County, MT from 2017 to 2023 Figure 67: Number of Non-fatal Drug Overdoses Resulting in Hospitalization by Visit Type, Age Group, and Sex in Gallatin County, MT in 2017-2022 174 Figure 68: Number of Drug Seizures by Year and Type in Gallatin County, MT from 2014 to 2023 Figure 69: Drug Seizures by Type* in Gallatin County, MT in 2014-2023 Figure 70: Percent of Adults Who Are Current Smokers or Smokeless Tobacco Users in Gallatin, Madison, and Park Counties, MT from 2016 to 2021 Figure 71: Percent of Adults Who Are Binge Drinkers* in Gallatin, Madison, and Park Counties, MT from 2016 to 2021 Figure 72: Percent of Surveyed Middle School Students Not Consuming Fruits or Vegetables in the Last 7 days in Gallatin County, MT from 2017 to 2023 Figure 73: Percent of Surveyed High School Students Not Consuming Fruits or Vegetables in the Last 7 Days in Gallatin County, MT from 2017 to 2023 Figure 74: Percent of Residents Experiencing Food Insecurity* in Gallatin County, MT, Statewide, and the United States in 2022 Figure 75: Percent of Surveyed Students Reporting at Least One Concussion from Playing a Sport or Being Physically Active in Gallatin County, MT from 2017 to 2023 Figure 76: Percent of Surveyed Students Sleeping Less than 8 Hours per Night, on Average in Gallatin County, MT from 2017 to 2023 Figure 77: Sexual Activity Indicators among Surveyed Middle School Students in Gallatin County, MT from 2017 to 2023 Figure 78: Sexual Activity Indicators among Surveyed High School Students in Gallatin County, MT from 2017 to 2023 Figure 79: Percent* of Adult Population that Report Not Completing Any Exercise in the Last 30 days by Age Group in Gallatin, Madison, and Park Counties, MT in 2016-2021 Figure 80: Percent of Surveyed Students That Report Not Being Physically Active for at Least 60 Minutes per Day in the Last Week in Gallatin County, MT from 2017 to 2023 Figure 81: Percent of Adults without A Medical Provider Appointment in 2+ Years in Gallatin, Madison, and Park Counties, MT from 2016 to 2021 Figure 82: Percent of Population without Health Insurance in Gallatin County, MT, Statewide, and the United States from 2013 to 2022 Figure 83: Percent of Hispanic or Latino Residents Who Are Uninsured in Gallatin County, MT, Statewide, and the United States from 2013 to 2022 175 Figure 84: Percent of Residents with Disabilities Who Are Uninsured in Gallatin County, MT, Statewide, and the United States from 2015 to 2022 Figure 85: Top Reasons for Delaying Needed Healthcare in Gallatin County, MT as of 2023 Figure 86: Number of Physicians by Type per 100,000 Residents in Gallatin County, MT, and Statewide as of 2022-2023 Figure 87: Emergency Department Visits per 1,000 Medicare (dual and non-dual) Beneficiaries by Race/Ethnicity in Gallatin County, MT from 2019 to 2020 Figure 88: Number of Residents per Mental Healthcare Provider in Gallatin County, MT, Statewide, and the United States from 2016 to 2023 Figure 89: Top Reasons for Not Accessing Mental Health Services in Gallatin County, MT as of 2023 Figure 90: Substance Abuse Service Facilities Accepting Medicaid per 1,000 in Gallatin County, MT from 2010 to 2020 Figure 91: Percent of Adults Unable to See a Medical Provider Due to Cost in the Last 12 months in Gallatin, Madison, and Park County, MT from 2016 to 2021 Figure 92: Monthly Number of Adults and Children Enrolled Traditional Medicaid in Gallatin County from October 2021 to December 2023 Figure 93: Monthly Traditional Enrollments among Blind/Disabled Residents, Pregnant Women, and Children in Foster Care in Gallatin County from October 2021 to December 2023 Figure 94: Percent of Population with Cash Public Assistance or SNAP in the Past 12 Months in Gallatin County, MT, Statewide, and the United States from 2013 to 2022 Figure 95: Annual Childcare Cost by Age of Child and Care Setting* in Gallatin County, MT Compared to Statewide, and National Averages in 2023 Figure 96: Percent of Housing Units by Occupant Type, Gallatin County, MT, Statewide, and the United States, 2022 Figure 97: Median Home Sale Price by Community in Gallatin County, MT and the United States as of 2023 Figure 98: Percent of Renters Spending >30% of Income on Rental Costs in Gallatin County, MT, Statewide, and the United States from 2013 to 2022 Figure 99: Percent of Surveyed Students Not Always Wearing a Seatbelt When Riding in a Car in Gallatin County, MT from 2017 to 2023 176 Figure 100: Percent of Adults Not Always Wearing a Seatbelt While Driving a Car in Gallatin, Madison, and Park Counties, MT from 2016 to 2021 Figure 101: Percent of Residents Commuting to Work by Transportation Type in Gallatin County, MT from 2016 to 2022 Figure 102: Percent of Homes Built before 1979 by Occupant Type in Gallatin County, MT, Statewide, and the United States in 2022 Figure 103: Point-in-time Homeless Population by Location Slept in Gallatin County, MT from 2019 to 2024* Figure 104: Percent of Kindergarten - High School Students Experiencing Homelessness by School Year in Gallatin County, MT and Statewide from 2012 to 2023 Figure 105: Average Annual Precipitation in Inches in Gallatin County, MT, 2004-2023 Figure 106: Number of Moderate to Hazardous Air Quality Days per Year in Gallatin County, MT from 2000 to 2023 LIST OF TABLES Table 1: Health Model Component Example Table 2: Summary of Annual COVID-19 Cases, Hospitalizations, and Deaths Reported among Gallatin, County, MT Residents from March 17, 2020 to July 31, 2024 Table 3: Leading Causes of Death by Race/Ethnicity in Gallatin County, MT 2012-2023 Table 4: Leading Causes of Death by Age Group in Gallatin County, MT 2012-2023 Table 5: Community Health Assessment Health Model Term Definitions Table 6: Health Model Categories, Themes, Topics, and Definitions Table 7: Community Committee Members by Organization and Sector Represented Table 8: Focus Group Discussion Recruitment Strategies Table 9: Focus Group Discussion Protocol Table 10: Data Biography Table 11: Data Inclusion Criteria 177 APPENDIX 8: REFERENCE LIST FOR FIGURES The following sources correspond to the in-text figure references. Figure 3 United States Census Bureau. (2022). Age and Sex. [American Community Survey, 5-year Estimated, Table S0101]. United States Census Bureau. https://data.census.gov/table?t=Age%20and%20Sex&g=040XX00US30_050XX00US30031 Figure 4 United States Census Bureau. (2020). Urban and Rural. [Decennial Census, Table H2]. United States Census Bureau. Retrieved from: https://data.census.gov/table?q=urban%20rural&g=050XX00US30031 Figure 5 United States Census Bureau. (2020). Hispanic or Latino, and Not Hispanic or Latino by Race. [Decennial Census, Table P9]. United States Census Bureau. Retrieved from: https://data.census.gov/table/DECENNIALDHC2020.P9?g=050XX00US30031 Figure 6 United States Census Bureau. (2020). Hispanic or Latino, and Not Hispanic or Latino by Race. [Decennial Census, Table P9]. United States Census Bureau. Retrieved from: https://data.census.gov/table/DECENNIALDHC2020.P9?g=050XX00US30031 Figure 7 United States Census Bureau. (2022). Language Spoken at Home. [American Community Survey, 5-year estimates, Table S1601]. United States Census Bureau. Retrieved from: https://data.census.gov/table/ACSST1Y2022.S1601?g=050XX00US30031 Figure 8 United States Census Bureau. (2022). Language Spoken at Home. [American Community Survey, 5-year estimates, Table S1601]. United states Census Bureau. Retrieved from: https://data.census.gov/table/ACSST1Y2022.S1601?g=050XX00US30031 Figure 9 United States Census Bureau. (2022). Comparative Social Characteristics in the United States. [American Community Survey, 5-year estimates, Table CP02]. United States Census Bureau. Retrieved from: https://data.census.gov/table?q=Native%20and%20Foreign%20Born&g=050XX00US30031&d=ACS%205- Year%20Estimates%20Comparison%20Profiles Figure 10 United States Census Bureau. (2022). Comparative Social Characteristics in the United States. [American Community Survey, 5-year estimates, Table CP02]. United States Census Bureau. Retrieved from: 178 https://data.census.gov/table?q=Native%20and%20Foreign%20Born&g=050XX00US30031&d=ACS%205- Year%20Estimates%20Comparison%20Profiles Figure 11 Montana Office of Public Instruction. (2023). Growth and Enhancement of Montana Student, Student Data, Interactive Dashboards. Montana Office of Public Instruction. Retrieved from: https://gems.opi.mt.gov/student-data Figure 12 Montana Department of Labor and Industry. (2023). Montana Labor Market Information, Local Area Profiles. Montana Department of Labor and Industry. Retrieved from: https://lmi.mt.gov/LocalAreaProfiles Figure 13 Montana Department of Labor and Industry. (2023). County/State: Montana Labor Market Information, Local Area Profiles. Montana Department of Labor and Industry. Retrieved from: https://lmi.mt.gov/LocalAreaProfiles United States Bureau of Labor Statistics. (2023). Current Employment Statistics- CES (National). United States Bureau of Labor Statistics. 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Retrieved from: https://www.census.gov/data/tables/time-series/demo/popest/2020s-counties-total.html Figure 20 United States Census Bureau. (2022). County Populations Totals and Components of Change: 2020-2023. [Single- race Population Estimates, Postcensal Estimates]. United States Census Bureau. Retrieved from: https://www.census.gov/data/tables/time-series/demo/popest/2020s-counties-total.html Figure 21 Regional Economic Models Incorporated. (2023). Montana State and County Population Projection by Gender, Race, and Age. Montana Department of Commerce. Retrieved from: https://dataportal.mt.gov/t/DOC/views/CEIC_REMI_POPULATION_PROJECTION_COUNTY_AGE_RACE_SFE /Trend?%3Aorigin=card_share_link&%3Aembed=y Figure 22 Centers for Disease Control and Prevention. (2022). [Percent of Adults Self-reporting Physically Unhealthy Days in the Past Month in Gallatin, Madison, and park Counties, MT from 2016-2021]. [Unpublished raw data from the Behavioral Risk Factor Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: lauren.white@mt.gov Figure 23 Centers for Disease Control and Prevention. (2021). [Percent of Adults Ages 18 Years or Older self-reporting Poor or Fair Health Status in Gallatin, Madison, and Park Counties, MT from 2016-2021]. [Unpublished raw data from the Behavioral Risk Factor Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: lauren.white@mt.gov Figure 24 United States Census Bureau. (2022). Disability Characteristics. [American Community Survey, 5-year estimates, Table S1810]. United States Census Bureau. Retrieved from: https://data.census.gov/table/ACSST5Y2022.S1810?q=Gallatin%20County,%20Montana&t=Disability 180 Figure 25 United States Census Bureau. (2022). Disability Characteristics. [American Community Survey, 5-year estimates, Table S1810]. United States Census Bureau. 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Surveillance for Certain Health Behaviors Among States and Selected Local Areas — Behavioral Risk Factor Surveillance System, United States, 2011 [National: Behavioral Risk Factor Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/mmwr/preview/mmwrhtml/ss6309a1.htm Centers for Disease Control and Prevention. (2021). Weight Classification by Body Mass Index (BMI) (variable calculated from one or more BRFSS questions). [State: Behavioral Risk Factor Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: https://nccd.cdc.gov/BRFSSPrevalence/rdPage.aspx?rdReport=DPH_BRFSS.ExploreByLocation&rdProcess Action=&SaveFileGenerated=1&irbLocationType=States&islLocation=30&islState=&islCounty=&islClass=C LASS14&islTopic=TOPIC09&islYear=2021&hidLocationType=States&hidLocation=30&hidClass=CLASS14&h idTopic=TOPIC09&hidTopicName=BMI+Categories&hidYear=2021&irbShowFootnotes=Show&rdICL- iclIndicators=_BMI5CAT&iclIndicators_rdExpandedCollapsedHistory=&iclIndicators=_BMI5CAT&hidPrevio uslySelectedIndicators=&DashboardColumnCount=2&rdShowElementHistory=divTopicUpdating%3dHide %2cislTopic%3dShow%2cdivYearUpdating%3dHide%2cislYear%3dShow%2c&rdScrollX=0&rdScrollY=0&rd Rnd=86738 PLACES: Local Data for Better Health. (2021). County PLACES: Local Data for Better Health. [Interactive Map, Health Outcomes]. Centers for Disease Control and Prevention. Retrieved from: https://experience.arcgis.com/experience/22c7182a162d45788dd52a2362f8ed65 181 Figure 29 Centers for Disease Control and Prevention. (2021). Diagnosed Diabetes- Total Adults Aged 18+ Years, Age- Adjusted Percentage, National. [United States Diabetes Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: https://gis.cdc.gov/grasp/diabetes/diabetesatlas-surveillance.html Figure 30 Gallatin City- County Health Department. (2024). [Monthly Covid-19 Hospitalizations in Gallatin County, MT from March 2020 to July 2024]. [Montana Infections Disease Information System]. Montana Department of Public Health and Human Services. Retrieved from: https://midis.hhs.mt.gov/nbs/ManageReports.do Figure 31 Gallatin City-County Health Department. (2024). [Monthly COVID-19 Cased in Gallatin County, MT from March 2020 to July 2024]. [Montana Infectious Disease Information System]. Montana Department of Public Health and Human Services. Retrieved from: https://midis.hhs.mt.gov/nbs/ManageReports.do Figure 32 Gallatin City-County Health Department. (2024). 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Retrieved from: https://midis.hhs.mt.gov/nbs/ManageReports.do Figure 35 Gallatin City-County Health Department. (2023). [Sexually Transmitted Disease Incidence in Gallatin County, MT from 2018 to 2023]. [Montana Infectious Disease Information System]. Montana Department of Public Health and Human Services. Retrieved from: https://midis.hhs.mt.gov/nbs/ManageReports.do Figure 36 Gallatin City-County Health Department. (2023). [Chlamydia and Gonorrhea Cases by Age Group in Gallatin County, MT from 2018 to 2023]. [Montana Infectious Disease Information System]. Montana Department of Public Health and Human Services. Retrieved from: https://midis.hhs.mt.gov/nbs/ManageReports.do 182 Figure 37 Gallatin City-County Health Department. (2023). [Vaccine Preventable Disease Incidence in Gallatin County, MT from 2014 to 2023]. [Montana Infectious Disease Information System]. Montana Department of Public Health and Human Services. Retrieved from: https://midis.hhs.mt.gov/nbs/ManageReports.do Figure 38 Bozeman Help Center. (2022). [Percent of Bozeman Help Center calls by Most Type in Gallatin County, MT from 2012 to 2022]. [Unpublished raw data]. Bozeman Help Center. Retrieved from: dataco@bozemanhelpcenter.org Figure 39 Centers for Disease Control and Prevention. (2021). [Percent of Adults Reporting 14+ Mentally Unhealthy Days in the Past Month in Gallatin, Madison, and Park Counties, MT from 2016-2021]. [Unpublished raw data from the Behavioral Risk Factor Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: lauren.white@mt.gov Figure 40 Centers for Disease Control and Prevention. (2023). [Mental Health Indicators among Surveyed Middle and High School Students in Gallatin County, MT from 2017 to 2023]. [Unpublished raw data from the Youth Risk Behavior Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: Genie.Zeeck@mt.gov Figure 41 Centers for Disease Control and Prevention. (2023). [Percent of Surveyed Students Reporting Poor Mental Health during Most or All of the Past Month in Gallatin County, MT from 2021 to 2023]. [Unpublished raw data from the Youth Risk Behavior Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: Genie.Zeeck@mt.gov Figure 42 Montana Department of Public Health and Human Services. (2018). Healthy Montana Families Needs Assessment, HMF Needs Assessment Dashboard. Montana Department of Public Health and Human Services. Retrieved from: https://dphhs.mt.gov/InteractiveDashboards/HMFNeedsAssessment Figure 43 Martin, J.A., Hamilton, B.E., Osterman, M.J.K., and Driscoll, A.K. (2021). National Vital Statistics Reports: Births: Final Data for 2019. 70(2). Centers for Disease Control and Prevention. Retrieved from: https://stacks.cdc.gov/view/cdc/100472 Office of Epidemiology and Scientific Support. (2022). County/State: Montana Kids Count Data Center. Montana Department of Public Health and Human Services. Retrieved from: https://datacenter.aecf.org/data/tables/10617-births-to-mothers-who-smoked-during-pregnancy-5-year- totals?loc=28&loct=5#detailed/5/4264-4319/true/2543,2454,2026,1983/any/20374 183 Osterman, M.J.., Hamilton, B.E., Martin, J.A., Driscol, A.K., and Valenzuela, C.P. (2022). National Vital Statistics. Births: final data for 2020. 70(17). Centers for Disease Control and Prevention. Retrieved from: https://stacks.cdc.gov/view/cdc/112078 Osterman, M.J.K., Hamilton, B.E., Martin, J.A., Driscoll, A.K., and Valenzuela, C.P. (2023). National Vital Statistics. Births: final data for 2021. 72(1). Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/nchs/data/nvsr/nvsr72/nvsr72-01.pdf Osterman, M.J.K., Hamilton, B.E., Martin, J.A., Driscoll, A.K., and Valenzuela, C.P. (2024). National Vital Statistics. Births: final data for 2022. 73(2). Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/nchs/data/nvsr/nvsr73/nvsr73-02.pdf Figure 44 National Centers for Health Statistics. (2022). [Leading Causes of Mortality with Age-adjusted Rates per 100,000 Population in Gallatin County, MT, Statewide, and the United States in 2018-2022]. [National: Provisional Mortality Statistics, 2018 through Last Week Request]. Centers for Disease Control and Prevention. Retrieved from: https://wonder.cdc.gov/mcd-icd10-provisional.html Office of Epidemiology and Scientific Support. (2022). [Leading Causes of Mortality with Age-adjusted Rates per 100,000 Population in Gallatin County, MT, Statewide, and the United States in 2018-2022]. [County/State: Vital Statistics Data Request]. Montana Department of Public Health and Human Services. Retrieved from: MRingel@mt.gov Figure 45 Office of Epidemiology and Scientific Support. (2022). [Years of Potential Life Lost before Age 75 for Leading Causes of Mortality in Gallatin County, MT in 2018-2022]. [Vital Statistics Data Request]. Montana Department of Public Health and Human Services. Retrieved from: MRingel@mt.gov Figure 46 Centers for Disease Control and Prevention. (2021). Interactive Atlas of Heart Disease and Stroke. Centers for Disease Control and Prevention. Retrieved from: https://nccd.cdc.gov/DHDSPAtlas/?state=County Figure 47 National Center for Health Statistics. (2022). [Infant Mortality Rate per 1,000 Live Births in Gallatin County, MT, Statewide, and the United States in 2013-2022]. [Infant Deaths: Linked Birth/ Infant Death Records]. Centers for Disease Control and Prevention. Retrieved from: https://wonder.cdc.gov/lbd.html Office of Epidemiology and Scientific Support. (2022). [Infant Mortality Rate per 1,000 Live Births in Gallatin County, MT, Statewide, and the United States in 2013-2022]. [County/State: Vital Statistics Data Request]. Montana Department of Public Health and Human Services. Retrieved from: MRingel@mt.gov Figure 48 Office of Epidemiology and Scientific Support. (2006). Montana Annual Vital Statistics Reports, 2006. [Data Request]. Montana Department of Public Health and Human Services. 184 Office of Epidemiology and Scientific Support. (2007). Montana Annual Vital Statistics Reports, 2007. [Data Request]. Montana Department of Public Health and Human Services. Office of Epidemiology and Scientific Support. (2008). Montana Annual Vital Statistics Reports, 2008. [Data Request]. Montana Department of Public Health and Human Services. Office of Epidemiology and Scientific Support. (2009). Montana Annual Vital Statistics Reports, 2009. [Data Request]. Montana Department of Public Health and Human Services. Office of Epidemiology and Scientific Support. (2010). Montana Annual Vital Statistics Reports, 2010. [Data Request]. Montana Department of Public Health and Human Services. 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Montana Department of Public Health and Human Services. Office of Epidemiology and Scientific Support. (2017). Montana Annual Vital Statistics Reports, 2017. [Data Request]. Montana Department of Public Health and Human Services. Office of Epidemiology and Scientific Support. (2018). Montana Annual Vital Statistics Reports, 2018. [Data Request]. Montana Department of Public Health and Human Services. Office of Epidemiology and Scientific Support. (2019). Montana Annual Vital Statistics Reports, 2019. [Data Request]. Montana Department of Public Health and Human Services. Office of Epidemiology and Scientific Support. (2020). Montana Annual Vital Statistics Reports, 2020. [Data Request]. Montana Department of Public Health and Human Services. Office of Epidemiology and Scientific Support. (2021). Montana Annual Vital Statistics Reports, 2021. Montana Department of Public Health and Human Services. Retrieved from: https://dphhs.mt.gov/assets/publichealth/Epidemiology/VSU/VSU2021AnnualReport.pdf Office of Epidemiology and Scientific Support. (2022). Montana Annual Vital Statistics Reports, 2022. Montana Department of Public Health and Human Services. Retrieved from: https://dphhs.mt.gov/assets/publichealth/Epidemiology/VSU/2022MTVitalStatisticsFinal.pdf 185 Figure 49 National Center for Health Statistics. (2021). [Birth Rate per 1,000 Population in Gallatin County, MT, Statewide, and the United States from 2016 to 2021]. [Natality Information: Live Births]. Centers for Disease Control and Prevention. Retrieved from: https://wonder.cdc.gov/natality.html Office of Epidemiology and Scientific Support. (2016). Montana Annual Vital Statistics Reports, 2016. [Data Request]. Montana Department of Public Health and Human Services. Office of Epidemiology and Scientific Support. (2017). Montana Annual Vital Statistics Reports, 2017. [Data Request]. Montana Department of Public Health and Human Services. Office of Epidemiology and Scientific Support. (2018). Montana Annual Vital Statistics Reports, 2018. [Data Request]. Montana Department of Public Health and Human Services. Office of Epidemiology and Scientific Support. (2019). Montana Annual Vital Statistics Reports, 2019. [Data Request]. Montana Department of Public Health and Human Services. Office of Epidemiology and Scientific Support. (2020). Montana Annual Vital Statistics Reports, 2020. [Data Request]. Montana Department of Public Health and Human Services. Office of Epidemiology and Scientific Support. (2022). Montana Annual Vital Statistics Reports, 2021. Montana Department of Public Health and Human Service. Retrieved from: https://dphhs.mt.gov/assets/publichealth/Epidemiology/VSU/VSU2021AnnualReport.pdf Figure 50 National Center for Health Statistics. (2022). [Age-adjusted Suicide Rate per 100,000 Population in Gallatin County, MT, Statewide, and the United States from 2016 to 2022]. [Mortality Data on CDC WONDER]. Centers for Disease Control and Prevention. Retrieved from: https://wonder.cdc.gov/Deaths-by-Underlying- Cause.html Office of Epidemiology and Scientific Support. (2016). Montana Annual Vital Statistics Reports, 2016. [Data Request]. Montana Department of Public Health and Human Services. Office of Epidemiology and Scientific Support. (2017). Montana Annual Vital Statistics Reports, 2017. [Data Request]. Montana Department of Public Health and Human Services. Office of Epidemiology and Scientific Support. (2018). Montana Annual Vital Statistics Reports, 2018. [Data Request]. Montana Department of Public Health and Human Services. Office of Epidemiology and Scientific Support. (2019). Montana Annual Vital Statistics Reports, 2019. [Data Request]. Montana Department of Public Health and Human Services. Office of Epidemiology and Scientific Support. (2020). Montana Annual Vital Statistics Reports, 2020. [Data Request]. Montana Department of Public Health and Human Services. Office of Epidemiology and Scientific Support. (2021). Montana Annual Vital Statistics Reports, 2021. Montana Department of Public Health and Human Services. Retrieved from: https://dphhs.mt.gov/assets/publichealth/Epidemiology/VSU/VSU2021AnnualReport.pdf 186 Office of Epidemiology and Scientific Support. (2022). Montana Annual Vital Statistics Reports, 2022. Montana Department of Public Health and Human Services. Retrieved from: https://dphhs.mt.gov/assets/publichealth/Epidemiology/VSU/2022MTVitalStatisticsFinal.pdf Figure 51 Centers for Disease Control and Prevention. (2023). [Suicide Indicators among Surveyed High School Students in Gallatin County, MT from 2017 to 2023]. [Unpublished raw data from the Youth Risk Behavior Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: Genie.Zeeck@mt.gov Figure 52 Centers for Disease Control and Prevention. (2023). [Suicide Indicators among Surveyed Middle School Students in Gallatin County, MT, from 2017 to 2023]. [Unpublished raw data from the Youth Risk Behavior Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: Genie.Zeeck@mt.gov Figure 53 National Center for Health Statistics. (2022). [Unintentional Injury Mortality Rates per 100,000 Population in Gallatin County, MT, Statewide, and the United States in 2018-2022]. [Mortality Data on CDC WONDER]. Centers for Disease Control and Prevention. Retrieved from: https://wonder.cdc.gov/Deaths-by- Underlying-Cause.html Office of Epidemiology and Scientific Support. (2022). [Unintentional Injury Mortality Rates per 100,000 Population in Gallatin County, MT, Statewide, and the United States in 2018-2022]. [County/State: Vital Statistics Data Request]. Montana Department of Public Health and Human Services. Retrieved from: MRingel@mt.gov Figure 54 National Center for Health Statistics. (2021). County-level Drug Overdose Mortality in the United States, 2003-2021. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/nchs/data- visualization/drug-poisoning-mortality/index.htm Figure 55 Trauma Systems & Injury Prevention Program. (2023). [Number of Fatal Drug Overdoses by Age Group and Sex in Gallatin County, MT from 2009 to 2023]. [Injury and Drug Overdose Indicators Dashboard]. Montana Department of Public Health and Human Services. Retrieved from: https://dphhs.mt.gov/publichealth/EMSTS/InjuryandOverdoseIndicators?fbclid=IwY2xjawEaDjlleHRuA2Fl bQIxMAABHb- Uey12_hKsM8eK5u55tsKHdtIF0qoh8fCj5bKO4VFec65Dleq2B27tPg_aem_a6HREvV2VOSkjRWy1J692w Figure 56 Trauma Systems & Injury Prevention Program. (2023). [Percent of Fatal Overdoses by Drug Type in Gallatin County, MT from 2009 to 2023]. [Injury and Drug Overdose Indicators Dashboard]. Montana Department of Public Health and Human Services. Retrieved from: https://dphhs.mt.gov/publichealth/EMSTS/InjuryandOverdoseIndicators?fbclid=IwY2xjawEaDjlleHRuA2Fl 187 bQIxMAABHb- Uey12_hKsM8eK5u55tsKHdtIF0qoh8fCj5bKO4VFec65Dleq2B27tPg_aem_a6HREvV2VOSkjRWy1J692w Figure 57 National Highway Traffic Safety Administration. (2022). [Annual Number of Vehicle-related Fatalities in Gallatin County, MT from 2003 to 2022]. [Fatality Analysis Reporting System]. United States Department of Transportation. Retrieved from: https://www-fars.nhtsa.dot.gov/Main/index.aspx Figure 58 National Highway Traffic Safety Administration. (2022). [Percent of Vehicle-related Fatalities by Vehicle Type in Gallatin County, MT from 2003 to 2022]. [Fatality Analysis Reporting System]. United States Department of Transportation. Retrieved from: https://www-fars.nhtsa.dot.gov/Main/index.aspx Figure 59 National Highway Traffic Safety Administration. (2022). [Percent of Vehicle Fatalities with Driver Blood Alcohol Content Greater Than or Equal to 0.08 in Gallatin County, MT, Statewide, and the United States from 2003 to 2022]. [Fatality Analysis Reporting System]. United States Department of Transportation. Retrieved from: https://www-fars.nhtsa.dot.gov/Main/index.aspx Figure 60 National Center for Health Statistics. (2022). [Intentional Injury Mortality Rate per 100,000 Population in Gallatin County, MT, Statewide, and the United States in 2018-2022]. [Mortality Data on CDC WONDER]. Centers for Disease Control and Prevention. Retrieved from: https://wonder.cdc.gov/Deaths-by-Underlying- Cause.html Office of Epidemiology and Scientific Support. (2022). [Intentional Injury Mortality Rate per 100,000 Population in Gallatin County, MT, Statewide, and the United States in 2018-2022]. [County/State: Vital Statistics Data Request]. Montana Department of Public Health and Human Services. Retrieved from: MRingel@mt.gov Figure 61 United States Census Bureau. (2022). Relationship by Household Type (Including Living Alone) for the Population 65 Years and Over. [American Community Survey, 5-year estimates, Table B09020]. United States Census Bureau. Retrieved from: https://data.census.gov/table/ACSDT1Y2022.B09020 Figure 62 Centers for Disease Control and Prevention. (2023). [Percent of Surveyed Students Reporting Being Bullied/Teased in Gallatin County, MT from 2017 to 2023]. [Unpublished raw data from the Youth Risk Behavior Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: Genie.Zeeck@mt.gov Figure 63 Centers for Disease Control and Prevention. (2023). [Percent of Surveyed Students Spending 3+ Hours per Day on Screen Time (Excluding Schoolwork) in Gallatin County, MT in 2021 and 2023]. [Unpublished raw data 188 from the Youth Risk Behavior Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: Genie.Zeeck@mt.gov Figure 64 Centers for Disease Control and Prevention. (2023). [Percent of Surveyed Students Using Social Media at Least Daily in Gallatin County, MT in 2023]. [Unpublished raw data from the Youth Risk Behavior Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: Genie.Zeeck@mt.gov Figure 65 Centers for Disease Control and Prevention. (2023). [Percent of Surveyed Middle School Students Indicating Substance Use in Gallatin County, MT from 2017 to 2023]. [Unpublished raw data from the Youth Risk Behavior Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: Genie.Zeeck@mt.gov Figure 66 Centers for Disease Control and Prevention. (2023). [Percent of Surveyed High School Students Indicating Substance Use in Gallatin County, MT from 2017 to 2023]. [Unpublished raw data from the Youth Risk Behavior Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: Genie.Zeeck@mt.gov Figure 67 Trauma Systems & Injury Prevention Program. (2023). [Number of Non-fatal Drug Overdoses Resulting in Hospitalization by Visit Type, Age Group, and Sex in Gallatin County, MT from 2017-2022]. [Injury and Drug Overdose Indicators Dashboard]. Montana Department of Public Health and Human Services. Retrieved from: https://dphhs.mt.gov/publichealth/EMSTS/InjuryandOverdoseIndicators?fbclid=IwY2xjawEaDjlleHRuA2Fl bQIxMAABHb- Uey12_hKsM8eK5u55tsKHdtIF0qoh8fCj5bKO4VFec65Dleq2B27tPg_aem_a6HREvV2VOSkjRWy1J692w Figure 68 Montana Statistical Analysis Center. (2024). Drug Seizures Statistics for All County. Montana Board of Crime Control. Retrieved from: https://dataportal.mt.gov/t/MBCC/views/CIM- DrugSeizures/DrugTrends_County?iframeSizedToWindow=true&%3Aembed=y&%3AshowAppBanner=fals e&%3Adisplay_count=n&%3AshowVizHome=n&%3Aorigin=viz_share_link Figure 69 Montana Statistical Analysis Center. (2024). Drug Seizures Statistics for All County. Montana Board of Crime Control. Retrieved from: https://dataportal.mt.gov/t/MBCC/views/CIM- DrugSeizures/DrugTrends_County?iframeSizedToWindow=true&%3Aembed=y&%3AshowAppBanner=fals e&%3Adisplay_count=n&%3AshowVizHome=n&%3Aorigin=viz_share_link 189 Figure 70 Centers for Disease Control and Prevention. (2021). [Percent of Adults Who Are Current Smokers or Smokeless Tobacco Users in Gallatin, Madison, and Park Counties, MT from 2016 to 2021]. [Unpublished raw data from the Behavioral Risk Factor Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: lauren.white@mt.gov Figure 71 Centers for Disease Control and Prevention. (2021). [Percent of Adults Who Are Binge Drinkers in Gallatin, Madison, and Park Counties, MT from 2016 to 2021]. [Unpublished raw data from the Behavioral Risk Factor Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: lauren.white@mt.gov Figure 72 Centers for Disease Control and Prevention. (2023). [ Percent of Surveyed Middle School Students Not Consuming Fruits or Vegetables in the Last 7 days in Gallatin County, MT from 2017 to 2023]. [Unpublished raw data from the Youth Risk Behavior Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: Genie.Zeeck@mt.gov Figure 73 Centers for Disease Control and Prevention. (2023). [Percent of Surveyed High School Students Not Consuming Fruits or Vegetables in the Last 7 Days in Gallatin County, MT from 2017 to 2023]. [Unpublished raw data from the Youth Risk Behavior Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: Genie.Zeeck@mt.gov Figure 74 Feeding America. (2022). Food Insecurity among the Overall Population in the United States. Feeding America. Retrieved from: https://map.feedingamerica.org/ Figure 75 Centers for Disease Control and Prevention. (2023). [Percent of Surveyed Students Reporting at Least One Concussion from Playing a Sport or Being Physically Active in Gallatin County, MT from 2017 to 2023]. [Unpublished raw data from the Youth Risk Behavior Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: Genie.Zeeck@mt.gov Figure 76 Centers for Disease Control and Prevention. (2023). [Percent of Surveyed Students Sleeping Less than 8 Hours per Night, on Average in Gallatin County, MT from 2017 to 2023]. [Unpublished raw data from the Youth Risk Behavior Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: Genie.Zeeck@mt.gov 190 Figure 77 Centers for Disease Control and Prevention. (2023). [Sexual Activity Indicators among Surveyed Middle School Students in Gallatin County, MT from 2017 to 2023]. [Unpublished raw data from the Youth Risk Behavior Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: Genie.Zeeck@mt.gov Figure 78 Centers for Disease Control and Prevention. (2023). [Sexual Activity Indicators among Surveyed High School Students in Gallatin County, MT from 2017 to 2023.] [Unpublished raw data from the Youth Risk Behavior Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: Genie.Zeeck@mt.gov Figure 79 Centers for Disease Control and Prevention. (2021). [Percent of Adult Population that Report Not Completing Any Exercise in the Last 30 days by Age Group in Gallatin, Madison, and Park Counties, MT from 2016 to 2021]. [Unpublished raw data from the Behavioral Risk Factor Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: lauren.white@mt.gov Figure 80 Centers for Disease Control and Prevention. (2023). [Percent of Surveyed Students That Report Not Being Physically Active for at Least 60 Minutes per Day in the Last Week in Gallatin County, MT from 2017 to 2023]. [Unpublished raw data from the Youth Risk Behavior Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: Genie.Zeeck@mt.gov Figure 81 Centers for Disease Control and Prevention. (2021). [Percent of Adults without A Medical Provider’s Appointment in 2+ years in Gallatin, Madison, and Park Counties, MT from 2016 to 2021]. [Unpublished raw data from the Behavioral Risk Factor Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: lauren.white@mt.gov Figure 82 United States Census Bureau. (2022). Selected Economic Characteristics. [American Community Survey, 5-year estimates, Table DP03]. United States Census Bureau. Retrieved from: https://data.census.gov/table?q=DP03&g=010XX00US_040XX00US30_050XX00US30031&y=2013&d=ACS %205-Year%20Estimates%20Data%20Profiles Figure 83 United States Census Bureau. (2022). Selected Characteristics of Health Insurance Coverage in the United States. [American Community Survey, 1-year estimates, Table S2701]. United States Census Bureau. Retrieved from: https://data.census.gov/table?q=S2701&g=040XX00US30_050XX00US30031 191 Figure 84 United States Census Bureau. (2022). Selected Characteristics of Health Insurance Coverage in the United States. [American Community Survey, 1-year estimates, Table S2701]. United States Census Bureau. Retrieved from: https://data.census.gov/table?q=S2701&g=040XX00US30_050XX00US30031 Figure 85 Bozeman Health. (2023). Bozeman Health Community Health Needs Assessment. Bozeman Health. Retrieved from: https://res.cloudinary.com/dpmykpsih/image/upload/bozeman-health-site- 321/media/52bcbdc15b574b2e93e8149baf0cc815/final-bozeman-health_2023_chna-report.pdf Figure 86 Health Resources and Services Administration. (2023). Area Health Resource Files. United States Department of Health and Human Services. Retrieved from: https://data.hrsa.gov/topics/health-workforce/ahrf Figure 87 Agency for Healthcare Research and Quality. (2020). [Emergency Department Visits per 1,000 Medicare (dual and non-dual) Beneficiaries by Race/Ethnicity in Gallatin County, MT from 2019 to 2020]. [Social Determinants of Health Database.] Agency for Healthcare Research and Quality. Retrieved from: https://www.ahrq.gov/sdoh/data-analytics/sdoh-data.html#download Figure 88 Centers for Medicare and Medicaid Services. (2023). CMS National Provider Identification Files. Centers for Medicare and Medicaid Services. Retrieved from: https://download.cms.gov/nppes/NPI_Files.html Figure 89 Bozeman Health. (2023). Bozeman Health Community Health Needs Assessment. Bozeman Health. Retrieved from: https://res.cloudinary.com/dpmykpsih/image/upload/bozeman-health-site- 321/media/52bcbdc15b574b2e93e8149baf0cc815/final-bozeman-health_2023_chna-report.pdf Figure 90 Agency for Healthcare Research and Quality. (2020). [Substance Abuse Service Facilities Accepting Medicaid per 1,000 in Gallatin County, MT from 2010 to 2020]. [Social Determinants of Health Database]. Agency for Healthcare Research and Quality. Retrieved from: https://www.ahrq.gov/sdoh/data-analytics/sdoh- data.html#download Figure 91 Centers for Disease Control and Prevention. (2021). [Percent of Adults Unable to See a Medical Provider Due to Cost in the Last 12 months in Gallatin, Madison, and Park County, MT from 2016 to 2021]. [Unpublished raw data from the Behavioral Risk Factor Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: lauren.white@mt.gov 192 Figure 92 Montana Department of Public Health and Human Services. (2023). [Monthly Number of Adults and Children Enrolled in Traditional Medicaid in Gallatin County from October 2021 to December 2023]. [Montana Medicaid Enrollment Dashboard]. Montana Department of Public Health and Human Services. Retrieved from: https://dphhs.mt.gov/interactivedashboards/medicaidenrollmentdashboard Figure 93 Montana Department of Public Health and Human Services. (2023). [Monthly Traditional Medicaid Enrollments among Blind/Disabled Residents, Pregnant Women, and Children in Foster Care in Gallatin County from October 2021 to December 2023]. [Montana Medicaid Enrollment Dashboard]. Montana Department of Public Health and Human Services. Retrieved from: https://dphhs.mt.gov/interactivedashboards/medicaidenrollmentdashboard Figure 94 United States Census Bureau. (2022). Public Assistance Income or Food STAMPS/SNAP in the Past 12 Months for Households. [American Community Survey, 5-year Estimated, Table B19058]. United States Census Bureau. Retrieved from: https://data.census.gov/table?q=B19058:%20Public%20Assistance%20Income%20or%20Food%20Stamps /SNAP%20in%20the%20Past%2012%20Months%20for%20Households&g=010XX00US_040XX00US30_050 XX00US30031&y=2013&d=ACS%205-Year%20Estimates%20Detailed%20Tables Figure 95 Women’s Bureau. (2023). Childcare Prices as a Share of Median Family Income by Age of Children and Care Setting. United States Department of Labor. Retrieved from: https://www.dol.gov/agencies/wb/topics/childcare/median-family-income-by-age-care-setting Figure 96 United States Census Bureau. (2022). Tenure. [American Community Survey, 1-year estimates, Table B25003]. United States Census Bureau. Retrieved from: https://data.census.gov/table?q=B25003&g=010XX00US_040XX00US30_050XX00US30031 Figure 97 Gallatin Association of Realtors. (2024). Gallatin Valley Housing Report 2024. Gallatin Association of Realtors. Retrieved from: https://heyzine.com/flip-book/40e8fd18e9.html United States Census Bureau. (2023). Monthly New Residential Sales, October 2024. United States Department of Commerce. Retrieved from: https://www.census.gov/construction/nrs/pdf/newressales.pdf Figure 98 United States Census Bureau. (2022). Comparative Housing Characteristics. [American Community Survey, 5-year estimates, Table CP04]. United States Census Bureau. Retrieved from: https://data.census.gov/table?q=population&g=010XX00US_040XX00US30_050XX00US30031&d=ACS%2 05-Year%20Estimates%20Comparison%20Profiles 193 Figure 99 Centers for Disease Control and Prevention. (2023). [Percent of Surveyed Students Not Always Wearing a Seatbelt When Riding in a Car in Gallatin County, MT from 2017 to 2023.] [Unpublished raw data from the Youth Risk Behavior Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: Genie.Zeeck@mt.gov Figure 100 Centers for Disease Control and Prevention. (2021). [Percent of Adults Not Always Wearing a Seatbelt While Driving a Car in Gallatin, Madison, and Park Counties, MT, 2016-2021]. [Unpublished raw data from the Behavioral Risk Factor Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: lauren.white@mt.gov Figure 101 United States Census Bureau. (2022). Means of Transportation to Work by Vehicles Available. [American Community Survey, 5-year estimates, Table B08141.] United States Census Bureau. Retrieved from: https://data.census.gov/table/ACSDT5Y2013.B08141?q=Percent%20of%20population%20getting%20to% 20work%20by%20transportation%20type&g=040XX00US30_050XX00US30031&tp=false&tid=ACSDT5Y20 14.B08141 Figure 102 United States Census Bureau. (2022). Tenure by Year Structure Built. [American Community Survey, 1-year estimates, Table B25036]. United States Census Bureau. Retrieved from: https://data.census.gov/table/ACSDT1Y2022.B25036?q=Year%20Structure%20Built&g=010XX00US_040X X00US30_050XX00US30031 Figure 103 Montana Continuum of Care Coalition. (2024). Homeless Population Point in Time Count 2024. Pathways Community Network Institute. Retrieved from: https://hrdc6.org/content/2024_MT_PiT_results.pdf Pathways Community Network Institute. (2022). [Point-in-time Homeless Population by Location Slept in Gallatin County, MT from 2019 to 2024]. [2019-2023: data request]. Retrieved from: christopher.sage@pcni.org Figure 104 Centers for Disease Control and Prevention. (2023). [Percent of Kindergarten - High School Students Experiencing Homelessness by School Year in Gallatin County, MT, and Statewide from 2012 to 2023]. [Unpublished raw data from the Youth Risk Behavior Surveillance System]. Centers for Disease Control and Prevention. Retrieved from: Genie.Zeeck@mt.gov Figure 105 National Centers for Environment Information. (2023). Climate at a Glance, County Time Series. National Oceanic and Atmospheric Administration. Retrieved from: https://www.ncei.noaa.gov/access/monitoring/climate- at-a-glance/county/time-series/MT-031/pcp/12/12/2000-2023 194 Figure 106 United States Environmental Protection Agency. (2023). Air Quality Index Report. United States Environmental Protection Agency. Retrieved from: https://www.epa.gov/outdoor-air-quality-data/air-quality-index- report 195 APPENDIX 9: REFERENCE LIST FOR IN-TEXT SOURCES The following sources correspond to the in-text endnote references. 1 Hood, C. M., Gennuso, K. P., Swain, G. R., & Catlin, B. B. (2016). County Health Rankings: Relationships Between Determinant Factors and Health Outcomes. American journal of preventive medicine, 50(2), 129–135. Retrieved from: https://doi.org/10.1016/j.amepre.2015.08.024 2 Agency for Healthcare Research and Quality (AHRQ). (2008). America’s health literacy: why we need accessible health information. Office of Disease Prevention and Health Promotion. Retrieved from: https://www.ahrq.gov/sites/default/files/wysiwyg/health-literacy/dhhs-2008-issue-brief.pdf 3 Program for the International Assessment of Adult Competencies. (2024). U.S. skills map: state and county indicators of adult literacy and numeracy. Retrieved from: https://nces.ed.gov/surveys/piaac/skillsmap/ 4 Mental Health in America. (2024). The state of mental health in America. Retrieved from: https://mhanational.org/issues/state-mental-health-america 5 National Center for Drug Abuse Statistics. (2021). Drug abuse statistics. Retrieved from: https://drugabusestatistics.org/#:~:text=Substance%20Abuse%20Statistics&text=13.5%25%20of%20Amer icans%2012%20and,drugs%20within%20the%20last%20year. 6 World Health Organization. (n.d.). Constitution of the World Health Organization. World Health Organization. Retrieved from: https://www.who.int/about/governance/constitution 7 Public Health Accreditation Board. (2022.). Standards & measures for reaccreditation version 2022. PHAB. Retrieved from: https://phaboard.org/wp-content/uploads/Standard-Measures-Version-2022- Reaccreditation.pdf 8 Hood, C. M., Gennuso, K. P., Swain, G. R., & Catlin, B. B. (2016). County Health Rankings: Relationships Between Determinant Factors and Health Outcomes. American journal of preventive medicine, 50(2), 129–135. Retrieved from: https://doi.org/10.1016/j.amepre.2015.08.024 9 World Health Organization. (2013, May 7). Social determinants of health: Key concepts. World Health Organization. Retrieved from: https://www.who.int/news-room/questions-and-answers/item/social- determinants-of-health-key-concepts 10 Centers for Disease Control and Prevention. (2024, May 14). Social Determinants of Health. Public Health Professionals Gateway. Retrieved from: https://www.cdc.gov/public-health-gateway/php/about/social- determinants-of-health.html 11 Healthy People 2030. (n.d.). Social Determinants of Health. Office of Disease Prevention and Health Promotion. Retrieved from: https://health.gov/healthypeople/priority-areas/social-determinants-health 12 Single-race Population Estimates, United States, 2020-2021. July 1st resident population by state, age, sex, single-race, and Hispanic origin, on CDC WONDER Online Database. Vintage 2021 estimates released by U.S. Census Bureau on June 30, 2022. United States Census Bureau. Retrieved from: https://wonder.cdc.gov/single-race-population.html 13 United States Census Bureau. (2023, September 16). Urban and rural. United States Census Bureau. Retrieved from: https://www.census.gov/programs-surveys/geography/guidance/geo-areas/urban-rural.html 196 14 United States Census Bureau. Urban Rural [Table H2]. United States Census Bureau. Retrieved from: https://data.census.gov/table?q=urban%20rural&g=040XX00US30_050XX00US30031&y=2010 15 United States Census Bureau. Urban Rural [Table H2]. 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