In assessing the overall health of Wayne County, clinical diagnoses take a backseat according to the recently released 2016 Community Health Assessment.

Education and socio-economic issues are often what determine the health of a community, said Wayne County Health Director Davin Madden.

Median household income, educational attainment and cultural biases are the three foundations that generate, "a lot of the time," the overal health and wellness of the community, Madden said.

Education translates to wealth and more wealth usually leads to better health, he said.

But cultural biases affect community health, too, he said, using an example of pregnancies among teenagers.

"Where you see disparities among ethnic groups because culturally, early pregnancies for example, may be more common in some cultures more than others, these things can have an impact, of course, if you have a child at 14," he said.

Madden explained that the likelihood of the teenage parent completing high school becomes scant, and with minimal education, acquiring a job "anywhere close to the median salary goes down."

That perpetuates the cycle of poverty and poor health, he said.

As of 2014, 22.5 percent of residents in Wayne County live in poverty and the median household income is $41,174.

The county's median income has steadily decreased over the past five years, while the state's median income average has shown a marginal increase at $46,693.

The average per capita income in Wayne County is $21,818, which is also lower than the state average.

Wayne County's unemployment rate is estimated at 6 percent.

The 2015 Community Health Assessment, released at the end of January, is a report that offers a snapshot of the health of the county and includes health conditions such as obesity, heart disease, cancer and diabetes, as well as mental health conditions.

The CHA also provides a glimpse at how the people in the county view their health and highlights the concerns which they believe affect their health.

These concerns are largely based in the socio-economic arena -- from poverty and crime, to housing and education, and also wages.

These components, compiled together, paint a picture of the health of the county.

The information is gleaned from surveys distributed at various facilities including WATCH, the library, the Wayne County Health Departments and the YMCA. Focus groups held at WATCH, the Community Soup Kitchen, low-income housing complex, the Boys and Girls Club, Literacy Connection and the Salvation Army, also contribute to the report.

"A county is not required to do both a survey assessment and a focus groups, however, we try -- if the staffing and resources allow -- we do both here in Wayne County to try to make sure what we are hearing from the focus groups are matching what is being answered on the surveys, to make sure the data collected are representative of the public's voice," Madden said.

From the data collected, the CHA determined three focus areas in Wayne County -- access to health care, education and health conditions.

ACCESS TO HEALTH CARE:

Twenty percent of the people in Wayne County are without health insurance coverage, the CHA determined.

According to the assessment, having insurance would provide people better access to health care.

"Health insurance helps individuals and families access needed primary care, specialists and emergency care. Having access to care allows individuals to enter the health care system, find care easily and locally, and get their health needs met," the report said.

In North Carolina, access to health care insurance has been limited with the state's refusal to expand Medicaid.

Under the Affordable Care Act, the option to expand Medicaid was presented to the North Carolina legislators and summarily rejected, citing high cost of the program.

Currently, Medicaid does not cover non-elderly, non-disabled adults with no children no matter their income. It does offer coverage to families with incomes of up to 50 percent of the federal poverty line.

Had Medicaid been expanded, the criteria for being approved for Medicaid would have been broadened, allowing for more people to get health insurance coverage who did not qualify for the ACA subsidies.

In Wayne County, around 39,000 individuals receive Medicaid.

Blue Cross Blue Shield of North Carolina said as of December 2016 there were 2,700 people who purchased an insurance policy individually in Wayne County.

BCBSNC refused to offer the number of people in Wayne County who purchased BCBSNC policies through the ACA marketplace, as well as how many people held BCBSNC policies through their employers.

The CHA also indicates that people without insurance are less likely to have a primary care provider and were likely to receive less "preventative care, dental care, chronic disease management and behavioral health counseling."

And uninsured or underinsured people are likely to have worse health outcomes once they are diagnosed with a health condition and more likely to die, according to the assessment.

EDUCATION:

Education is directly correlated with an individual's ability to achieve a healthier lifestyle through knowledge about self care and the ability to make money through gainful employment to finance preventative care needs and to acquire insurance.

"Research not only indicates how education has a tendency to lead to better jobs and high incomes, it also proves that better-educated individuals typically live longer, healthier lives than those with less education," the CHA cites.

The graduation rate in Wayne County is 85.1 percent -- just below the state average of 85.6 percent.

Around 82 percent of residents in Wayne County are high school graduates, with nearly 10 percent not having completed high school or earned a GED.

But over a four-year span, between 2010 to 2014, the dropout rate dropped from 67.4 per 1,000 to 38.5 per 1,000 teenagers. In that same span, the county recorded a dramatic decline in teenage pregnancies

"The efforts of health education, access to care, contraception and birth control (to include abstinence), and the endless public health partnership support between communities and the schools have made all this possible," according to the CHA.

The assessment recommends that none of these programs be decreased or eliminated "to prevent a spike or reversal to past pregnancy rates."

HEALTH CONDITIONS:

Cancer and heart disease are the top two leading causes of death in Wayne County, which aligns with the state.

Cancer is the leading cause of death for white and African-American men as well as African-American women. Heart disease is the leading cause of death among white women in the county.

The county was projected to have 710 new cancer cases in 2015 with breast cancer having the most new cases. In 2015, it was projected that 252 would die from cancer.

"For some cancers, such as lung cancer, prevention is more valuable than early detection," reports the CHA.

"As for many other types of cancer, early detection is extremely important. For example, breast cancer has a higher chance of being curable with early detection."

In Wayne County, breast cancer occurs at a rate of 143.8; prostate cancer occurs at a rate of 140.3; lung cancer occurs at a rate of 77.5; and colon cancer occurs at a rate of 46.1.

Heart disease is the second leading cause of death in the county at the rate of 182.4 per 100,000, which is slightly higher than the state rate.

Diabetes has become the fifth leading cause of death in the county and obesity and physical activity exacerbating the other health problems.

Thirty-five percent of people in the county are obese, according to the CHA.

"In addition, physical inactivity is also directly related to the prevalence of obesity, diabetes and heart disease," reports the CHA.

Twenty-seven percent of adults ages 20 and up report being physically inactive.