Running head: POPULATION HEALTH IN CITRUS COUNTY

Population Health in Citrus County

Garrett Mongelluzzo
University of South Florida

POPULATION HEALTH IN CITRUS COUNTY

Population Health in Citrus County

Founded in 1887, Citrus County is known for its many springs, manatees, and beautiful
sunsets. The purpose of this paper is to better understand the people and culture of Citrus County.
This paper will identify health indicators of strength and need in order to identify areas for
improvement.
Community Assessment and Local Findings
Citrus County is situated on Floridas Nature Coast along the Gulf of Mexico, 60 miles
north of Orlando and 70 miles north of Tampa (Citrus County Board of County Commissioners
(2012). According to the United States Census Bureau (2015), Citrus County is home to
approximately 141,058 people. Duke Energy, Citrus Memorial Hospital (CMH), and The Citrus
County Sherriffs office are three major employers of Citrus County. CMH and the Seven Rivers
Regional Medical Center are the two major hospitals in Citrus County. Of all families in Citrus
County, 20.1% are living in poverty compared to the state of Florida at 16.5%. (United States
Census Bureau, 2015). In Citrus County, 86.8% of residents twenty-five years or older have
graduated from high school compared to the state of Florida at 86.5% (United States Census
Bureau, 2015). Only 5.9% of Citrus County occupants over the age of five speak a different
language at home. This is much lower than the 27.4% of Floridians that do communicate in a
different language at home (Florida Department of Health, 2014). There are Physicians rate of
259.30 certified physicians per 100,000 people in Citrus County (Florida Department of Health,
2014). This is on par with the overall state rate of 259.25 licensed physicians per 100,000 in
population (Florida Department of Health, 2014).

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Health Indicators of Strength

Many factors go into the overall health status of a county. According to the World Health
Organization (WHO) (2016), social determinants of health are the living situations that impact
overall health and quality of life. County Health Rankings was the resource used to identify the
health indicators of strength in Citrus County. A Citrus County strength is that preventable stays
in the hospital per 1,000 Medicare clients is lower in Citrus (49) than the state of Florida (55)
(County Health Rankings, 2016). This could be attributed to a lower percentage of uninsured
residents. Citrus County has a lower percentage of population under age 65 without health
insurance (22%) than the state of Florida (24%) (County Health Rankings, 2016). Citrus County
also has a higher percentage of Medicare clients that are diabetic and obtain HbA1c monitoring
(88%) than the state of Florida (85%) (County Health Rankings, 2016). The percentage of
females enrolled in Medicare aged 67-69 residing in Citrus County that receive mammography
screening is 71%, which is higher than the state of Florida (68%) (County Health Rankings,
2016).
Health Indicators of Need
County Health Rankings was also the resource used to identify the health indicators of
need in Citrus County. In many cases, one area of need will directly affect another. For example,
areas of need such as physical inactivity and lack of exercise opportunities can affect the rate of
obesity. In Citrus County the rate of adult obesity is 27% compared to 25% of the state of Florida
(County Health Rankings, 2016). A health indicator that could lead to higher rates of obesity is a
lack of physical activity. Adults aged 20 and over claim that there is little leisure time for
physical activity is 28% in Citrus County, higher than the state of Florida at 24% (County Health
Rankings, 2016). Furthermore, 84% of Citrus County residents have access to exercise

POPULATION HEALTH IN CITRUS COUNTY

opportunities (County Health Rankings, 2016). This is significantly lower than the 92% of
Floridians that have access to exercise opportunities (County Health Rankings, 2016).
Children living in poverty are another health indicator of need. In Citrus County, 34% of
children are in poverty compared to the 24% of children in poverty in the state of Florida
(County Health Rankings, 2016). This can be attributed to the percentage of unemployed Citrus
County residents 16 years of age or older that are without a job. The percentage of Citrus county
residents 16 years or older that are unemployed is 8.5%, higher than to the state of Florida, which
is at 6.3% (County Health Rankings, 2016). Citrus County also has a less post-secondary
education than the rest of the state. The percentage of adults residing in Citrus between 25-44
years old that have any college instruction is 49%, compared to the state of Florida at 61%
County Health Rankings, 2016).
Citrus County also experiences higher rate of premature death than the state of Florida.
The years lost of potential life before the age of 75 per 100,000 people is 9,900 in Citrus County
compared the 6,800 years lost of potential life per100,000 people in the state of Florida (County
Health Rankings, 2016). A contributing factor could be deaths due to injury. The number of
injury deaths per 100,000 people in Citrus County is 113, compared to the 68 injury deaths per
100,000 people in Florida (County Health Rankings, 2016).
Identification of a Priority Health Issue
A priority health issue in Citrus County is the percentage of obese adults residing there.
The percentage of adults in Citrus County that are obese (27%) is higher than the state (25%) and
national benchmarks (25%)(County Health Rankings, 2016). Many people consider obesity to be
an epidemic that is greatly affecting the overall health of the American people. According to the
Centers for Disease Control and Prevention (CDC) (2016), obesity is a severe worry that is

POPULATION HEALTH IN CITRUS COUNTY

linked with poor health consequences, a decreased quality of life, and is a leading cause of death
in this county. This is due to obesity being associated with increased risk of heart disease,
diabetes, hypertension, cancer, and lifelong conditions (National Institute of Health, 2013).
Discussion and Application of Community Health Models
The goal of the Determinants of Health Model (DMH) is to use a multitude of factors to
determine the overall health of people. The DMH include the social environment, economic
environment, the physical environment, and someones own behaviors and characteristics
(World Health Organization, 2016). Other factors that factor in the overall health of a person are
socioeconomic status, education, genetics, health services, social support, and gender (World
Health Organization, 2016). Rather than a single gene being responsible for someone being
obese, most obesity is a result of complex interactions between multiple genes and the
environmental factors (CDC, 2016).
Biological factors, impact on the health system, environmental factors, and lifestyle
factors can all play a role in somebody being obese. While biological factors such as genetics
certainly do not factor in the most in regards to obesity, variations of numerous genes might play
a role in obesity by causing increased hunger, which leads to increased food intake (CDC, 2016).
Obesity has had a major influence on the countrys healthcare system. In 2008, the cost of
healthcare related to obesity was approximately $147 billion. Environmental and lifestyle factors
are believed to play a larger role in the obesity crisis. The environment that someone lives may
directly play a role in someones weight. A person may avoid walking or biking due to an unsafe
neighborhood or lack of a sidewalk. A community may lack areas for exercise opportunities such
as parks or gyms. A family of a lower socioeconomic status may only be able to afford
processed, cheaper foods, opposed to fresh meat and produce. A persons lifestyle directly affects

POPULATION HEALTH IN CITRUS COUNTY

whether or not they become obese. It is recommended that a person partake in 150 minutes of
moderate activity or intense activity for roughly 75 minutes, or a mixture of both, while
participating in strength training for two days each week (CDC, 2016). If an individual does not
engage in physical activity or healthy eating, they are much more likely to become obese, which
puts them at a elevated possibility of cardiovascular disease, diabetes, and many other health
conditions.
Population Diagnosis
Citrus County residents that are obese are at an increased risk for health complications and
conditions that are related to obesity. County Health Rankings (2016) indicates that 27% of
adults are currently obese compared to the 25% for the state of Florida. The percentage of obese
residents in Citrus County is also above the national benchmark of 25% (County Health
Rankings, 2016). Every two out of three people is believed to be either obese or overweight
(National Institute of Diabetes and Digestive and Kidney Disease, 2012). Obesity can lead to an
elevated possibility of cardiovascular disease, diabetes, hypertension, cancers, and various
chronic conditions (National Institute of Health, 2013).
Community-based Primary Level of Prevention
The goal of primary prevention levels is to prevent any injury and disease prior a harmful
event taking place (Trulio-Londrigan & Lewenson, 2013). A focus of the primary prevention of
obesity should center around children and young adults. Education on the importance of eating
healthy and regular physical activity should be provided to children. Schools can promote
physical activity through comprehensive school physical activity programs, including recess,
classroom-based physical activity, intramural physical activity clubs, interscholastic sports, and
physical education (CDC, 2015). Community health nurses should constantly promoting

POPULATION HEALTH IN CITRUS COUNTY

healthy eating and regular physical activity to their patients and educate them that these
interventions can improve strength, endurance, reduces stress, and help control their weight.
Community-based Secondary Level of Prevention
The focus of secondary prevention measures should be intended for individuals that are
currently obese. Secondary prevention measures are those related to preventing the progression
of disease in the early stages (Trulio-Londrigan & Lewenson, 2013). Being obese greatly
increases a persons risk of developing type 2 diabetes. Screening for diabetes should take place
in people 30 years or older who are at risk of developing type 2 diabetes, those without risk
factors over 45 years old, those with a sustained blood pressure of greater than 135/80 mmHg,
and people with a BMI of 25 or greater and one or more additional risk factors for diabetes
(American Family Physician, 2010). Healthcare providers are responsible for screening these
individuals. The community nurse should be educating their patients about monitoring and
preventing the progression of type 2 diabetes. Examples of this would be keeping blood glucose
logs, regular exercise, diet, regular eye exams, etc.
Community-based Tertiary Level of Prevention
Tertiary levels of prevention deal with helping individuals manage or reduce the negative
effects of disease (Trulio-Londrigan & Lewenson, 2013). Type 2 diabetes is a very common
result of obesity. Obese individuals need continuous treatment and disease management to avoid
a pre-mature death. Insulin and oral medications should be used to help regulate blood glucose.
Physical activity and weight management are also a critical part of the tertiary prevention
measures in addition to monitoring blood glucose levels. These interventions should help to
manage type 2 diabetes. Diet and exercise can have long-term benefits. It is very important for an
obese person with diabetes to take control of their disease and work to manage it. Patients can

POPULATION HEALTH IN CITRUS COUNTY

also engage in shared medical visits. Shared medical visits have a one-on-one session with a
clinician for the purposes of conducting an individualized visit to assess and treat the disease and
comorbidities, followed by a longer session in which participants interact about how to manage
their disease and learn self-care behaviors in a group setting (Ridge, 2012) . Community nurses
need to ensure they are educated on the available programs and are making sure they
communicate these available resources to their patients.
Reflection and Synthesis of Health Policy
Health policies have proven to be effective and have demonstrated substantial
improvements in public health (Brownson, 2009). An explicit health policy can achieve several
things: it defines a vision for the future which in turn helps to establish targets and points of
reference for the short and medium term (World Health Organization, 2016). The health policy
proposal for Citrus County is to mandate school program requirements that involve physical
activity such as recess, classroom-based physical activity, and physical education. This goal of
this proposal is aimed at primary prevention to teach children the importance of physical activity
and healthy living to prevent obesity. Students should be given access to recess at least 30
minutes per day and receive physical education five days a week. High-quality physical
education programs involve instruction by certified physical education teachers, a minimum of
150 minutes per week (30 minutes per day) for children in elementary schools and 225 minutes
per week (45 minutes per day) for students in middle and high schools (Kohl & Cook, 2013).
Stakeholders affected by the health policy are students, teachers, legislators, and health care
providers. Funding would be a concern, as many people that already oppose physical education
and recess in school would argue that an increase in resources would shrink an already declining
school budget. It is expected that parents and supporters of HEPA (Healthy Eating and Physical

POPULATION HEALTH IN CITRUS COUNTY

Activity) would support an increased presence of physical activity and focus on overall health in
schools. The Citrus County School Board would be contacted in an effort to get this
implemented into the school system. If successful, the health policy could greatly reduce the
incidence of adult and childhood obesity with primary prevention through healthy eating and
physical activity. Underserved children would benefit because they would be provided
opportunities for physical activity and taught the benefits of exercise and healthy eating. By
raising children in environments that foster healthy eating and regular exercise, children value
these things at a young age and carry them into adulthood. This could lower the adult obesity
rates and hopefully decrease the incidence of diabetes, cardiovascular disease, and other diseases
common to todays population.
Conclusion
Citrus County has beautiful rivers, sunsets, and wildlife for people to experience.
Overall Citrus County residents commonly utilize healthcare providers as evidenced by the rates
of mammogram screenings, preventable hospital stays, and number of uninsured residents when
compared to the state of Florida. With that said, there is clearly great room for improvement,
especially in regards to obesity, opportunities for exercise, children living in poverty, and
unemployment. As a future nurse, the main thing I take away from this paper is that obesity is a
global crisis that affects millions of individuals everyday. As a nurse, it is very important to be
knowledgeable about the healthy eating and exercise. We should be current with guidelines and
recommendations regarding exercise and healthy eating. Sadly, obesity is not something that is
going to be resolved quickly; therefore, a nurse needs to be able to educate a patient about
diabetes and how they can best manage their condition. Hopefully by teaching young children

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and young adults about the importance of maintaining overall good health through healthy eating
and regular exercise we can beat the obesity epidemic together.

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References
American Family Phyisican (2010). Diabetes Mellitus: Diagnosis and Screening. Retrieved from
http://www.aafp.org/afp/2010/0401/p863.html#sec-2
Brownson, R. C., Chriqui, J. F., & Stamatakis, K. A. (2009). Understanding Evidence-Based
Public Health Policy. American Journal of Public Health, 99(9), 15761583.
Centers for Disease Control and Prevention. (2015). Adult Obesity Causes & Consequences.
Retrieved from https://www.cdc.gov/obesity/adult/causes.html
Centers for Disease Control and Prevention (2016). Behavior, environment, and genetic factors
all hve a role in causing people to be overweight and obese. Retrieved from
https://www.cdc.gov/genomics/resources/diseases/obesity/
Citrus County Board of County Commissioners (2012). A Little History. Retrieved from
http://www.citrusbocc.com/aboutus/history.htm.
County Health Rankings (2016). Health outcomes. Retrieved from
http://www.countyhealthrankings.org/app/florida/2016/rankings/citrus/county/outcomes/o
verall/snapshot
Florida Department of Health (2014). Population at the age of 5 and over that speak a language
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Kohl, H. W., Cook, H. D. (2013). Educating the student body. Taking physical activity and
physical education to school. Retrieved from
http://www.ncbi.nlm.nih.gov/books/NBK201500/

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National Institute of Diabetes and Digestive and Kidney Disease (2012). Overweight and obesity
statistics. Retrieved from https://www.niddk.nih.gov/health-information/healthstatistics/Pages/overweight-obesity-statistics.aspx
National Institute of Health (2013). Why Obesity is a Health Problem. Retrieved from
http://www.nhlbi.nih.gov/health/educational/wecan/healthy-weight-basics/obesity.htm\
Ridge, T. (2012). Shared medical appointments in diabetes care: A literature review. Diabetes
Spectrum. 25(2). 72-75.
Trulio-Londrigan, M., Lewenson, S.B. (2013). Public Health Nursing: Practicing PopulationBased Care. Burlington, MA: Jones & Bartlett Learning
United States Census Bureau (2015). Citrus County, Florida. Retrieved from
http://www.census.gov/quickfacts/table/PST045215/12017.
United States Census Bureau (2015). Florida QuickFacts. Retrieved from
http://www.census.gov/quickfacts/table/PST045215/12
World Healh Organization (2016). Health policy. Retrieved from
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