State of the County Health Report

Click Here for the 2008 State of the County Health Report

Click Here for the SOTCH Brochure

 

 

 

State of the County Health Report

Madison County, North Carolina

December 2009

 

The 2009 State of the County Health Report highlights community health indicators for Madison County, the progress made during this year to address these indicators, as well as the identification of current health status data and examination of new community initiatives and emerging health issues for the year 2010.

 

 

Review of Health Status Data

As of 2008, there were 20,432 people living in Madison County, reflecting a four percent population growth since 2000.  Additional demographic data of interest includes the following statistics.  There are more than 8000 households and 5,592 families residing in the county.  Twenty-eight percent of these households have children under the age of 18 years living in them.  The average household size is 2.34 persons and the average family size is 2.81.  The county is predominantly Caucasian (97.2%) while small percentages of the population are Black, American Indian, Hispanic and Asian.  Males comprise 49% of the population; females total 51%. 

 

Per capita income in 2000 was $16,076 compared to the state $20,307.  The median household income for 2007 was $37,691 compared to the state $44,772.  Over 19% of the elderly population in Madison County lives in poverty and nearly 22% of children are living in poverty.  Almost 18% of the population is uninsured with nearly 400 children have no insurance.  Socioeconomic status is often measured by income which provides a direct measure of the quality of food, housing, and health care an individual is able to acquire, as well as reflecting their position in society.  Low socioeconomic status limits many from accessing preventive health care and participating in positive health behaviors.  In addition, very often practicing healthy behaviors is more costly for individuals and families.  Residents with limited incomes find these behaviors must take a back seat when trying to meet basic needs for the family. 

 

 

 

 

 

 

 

 

 

 

Review of Health Status Data (cont)

 

 

SOURCE:  U.S. Census

 

In a community survey for the 2007 Community Health Assessment, affordability of health care services was identified as a major concern.  Many noted difficulty getting the health care, dental care and prescriptions they needed because of limited incomes.

Thirty percent of Madison County residents have less than a high school education.  This percent is higher in comparison to the state and to other rural North Carolina counties.  Dropout rates have declined with 74% of students completing four years of high school.  Children whose parents have not completed high school and who are unemployed are five times more likely to drop out of school. 

 

Education has been shown to be an important predictor of health outcomes.  Research shows that lower levels of education are associated with poor health while higher education levels are associated with better health.  Overall mortality rates, including cancer and heart disease are higher for individuals with low educational status.  Low education levels can negatively affect an individual’s ability to process and understand health information and concepts.  This must be considered when developing intervention strategies for the individual and the community.

 

Within the 2007 community survey, several respondents expressed concerns about environmental issues such as air and water pollution and illegal dumping.  Madison County residents place a high emphasis on the environment and its protection.  There are no major factories or industries in the county that emit hazardous pollutants.  The percentage of impaired surface waters is very low.  Substandard housing has contributed to straight-piping into area streams.  The health department has led efforts to work with home owners, volunteer programs and other county agencies to reduce this problem.  Poor water quality can directly affect the health of those who use local rivers for recreation such as fishing and rafting.  Such pollutants can create food or water borne illnesses that impact individuals, families and communities.  Managing our natural resources is vital to promoting the county’s tourism industry as well as protecting the county’s health.

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Review of Health Status Data (cont)

 

The Madison County Health Department completed a comprehensive community health assessment in 2007 to gain an understanding of the health issues and concerns in our community.  From this information, the following priorities were identified:

            ►  Chronic Disease Issues                        ►  Access to Health Services

            ►  Child Health Concerns                           ►  Low Income/Poverty Concerns 

            ►  Mental Health Issues

           

 

The median age for Madison County is 39.3 years.  For North Carolina, the median age is 35.3 years.  One-fourth of the county’s population is 45-64 years of age.  Nearly 17% of the population is 65 years of age and older compare to the state’s 12%.   By the year 2020, trend data from the North Carolina Division of Aging notes that 20.6% of the population will be 65+ years of age.

 

 

Due to the small population of the county, many vital statistics such as morbidity and mortality data must be assessed by three- or five-year rates in order to obtain a true picture of the population’s health status.  According to the North Carolina State Center for Health Statistics, the ten leading causes of death for all ages, the death rate for Madison County and the death rate for North Carolina (2004-2008) are listed below:

 

SOURCE: Division of Public Health; State Center for Health Statistics

            Rank

Cause of Death

Madison County Rate

N.C. Rate

1

Cancer-All Sites

285.5

192.0

2

Diseases of the Heart

251.3

196.8

3

Cerebrovascular Disease

67.5

52.2

4

Chronic Lower Respiratory Disease

67.5

46.2

5

Alzheimer’s Disease

44.0

26.9

6

Pneumonia and Influenza

39.1

19.4

7

Septicemia

38.1

14.2

8

Other Unintentional Injuries

36.2

28.0

9

Motor Vehicle Injuries

25.4

18.7

10

Pneumonitis due to solids and liquids

20.5

NA*

*State data “ Not Available”

 

 

 

 

 

 

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Review of Health Status Data (cont)

 

Cancer is the leading cause of death in Madison County.  In 2007, 62 Madison County residents died from cancer.  It is estimated that by the year 2015, nearly one in four North Carolinians will develop cancer during their lives.  The majority of cancer deaths occur at five sites:  lung, colon, female breast, prostate, and pancreas.  

 

SOURCE:  N.C. Cancer Central Registry

 

It is generally accepted that over 60% of all cancers are related to personal lifestyle or environmental factors, such as smoking and diet, and therefore are preventable.

 

 

Child health data reflects many areas in need of prevention and intervention strategies.  There were five child deaths for ages 0-17 years from 2002-2006.  Each death had a different cause, showing no special trends.  Major child health concerns are related to  child maltreatment.  Rates of child maltreatment for cases that are investigated are nearly twice the rates for the state of North Carolina.  And unfortunately, the rates for substantiated child maltreatment is double the state rates.  Clearly, the community is aware of how to report suspicions of child maltreatment.  However, there are few resources available to address preventive measures.  Other child health concerns are related to mothers smoking during pregnancy, which is nearly twice the state rate; high rates of childhood obesity; and high rates of child poverty.  There are some positive child health statistics of note such as the five year birth rate for Madison County is 10.7 compared to the North Carolina rate of 14.1.  The five-year rate from 2002-2006 for infant mortality is 1.9 compared to the state rate 8.4.  Teen pregnancy rates for ages 15-19 years have consistently been lower than state rates for many years. 

 

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Review of Health Status Data (cont)

 

In 2006, North Carolina had the fifth highest rate of obese children in the nation.  This may be the first generation of children and youth in history to have a shorter life expectancy than their parents due to obesity-related health problems.  In 2006, 32% of North Carolina children 6-17 years of age were identified as obese or overweight.  For two years, the child health committee for the Madison Community Health Consortium has collected height, weight, and BMI (Body Mass Index) for all school children Kindergarten through 8th grade.  Madison County children have higher percentages for “overweight” or “at risk for overweight” than state percentages.  A state-wide task force on preventing childhood obesity has developed a framework of initiatives to address this critical issue.  This framework will be used as a guide for implementing community health strategies in the coming year for Madison County children and families.

 

 

SOURCE:  Madison County Health Department BMI Data Collection 2008-2009

 

 

 

Health Disparities

While Americans as a group are healthier and living longer, segments of the population continue to suffer poor health status.  Differences in the incidence and prevalence of health conditions and health status between groups are referred to as health disparities.  Most health disparities affect groups because of socioeconomic status, race/ethnicity, disability status, geographic location or a combination of these.  People in such groups experience worse health and also tend to have less access to social determinants that support health such as healthy food, good housing, and good education.  Within Madison County, health disparate groups include the unemployed, the uninsured/underinsured, the graying population and those without a high school education. 

 

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Health Disparities (cont)

 

The geographic layout of the county and a lack of transportation services are disadvantages that add to the health inequities experienced by such groups.  Lower income and fixed income families are less likely to have access to transportation and other health resources.  Adults with less than a high school education are less likely to visit a doctor and are three times more likely to be unemployed.  Interventions must consider the county’s societal conditions, health behaviors of disparate groups, and their access to health care in order to affect health outcomes.

 

 

 

Madison Community Health Consortium

The Madison Community Health Consortium is a partnership that seeks to improve the overall health of Madison County citizens by networking with community agencies and groups in an on-going process of needs assessment, project development, implementation, and evaluation.  The health consortium is a certified Healthy Carolinians’ partnership and has been active for 20 years.  It provides a forum for citizens, community agencies, groups and businesses to identify health issues of Madison County and to seek solutions for those needs. 

 

The Madison Community Health Consortium welcomes volunteers that may have a special interest in the health needs of the community.  Interested individuals may contact the Madison County Health Department for consortium information and meeting dates.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Tracking Progress of Health Priorities

 

The Madison Community Health Consortium, a Healthy Carolinians’ partnership, selected three priorities to actively address:  Chronic Disease, Child Health; and Mental Health.  Consortium and committee members opted to incorporate access to health services and low income/poverty concerns within the action plans for each of the three main priorities.

 

Priority-  Chronic Disease Issues

Progress

► Consortium Objective:

Decrease the number of hospitalizations related to chronic conditions such as heart disease, respiratory disease, diabetes, and cerebrovascular disease.

 

The Healthy People 2010 Objective is to reduce heart disease and diabetes death rates.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

√  Collaboration with local providers to offer a variety of free activities including options for physical, emotional, creative, and intellectual activities for adults age 55 and over during “Active Aging Week” the last week of September each year.

√  “Living Healthy”- evidenced based chronic disease self management program 6 week program that is free of charge through partnership with Land of Sky, Area Agency on Aging-2 successful programs facilitated 2008-2009. 

√  Active Aging Activities at Senior Nutrition Sites-Promoting opportunities for physical activity for adults 55 years of age and older through collaboration with local physical activity providers, Madison Community Services, Mars Hill College, and Madison County Senior Games.

√  Collaborate with Madison County Health Department and

Hot Springs Health Program to provide flu immunizations at a minimal cost and free blood glucose screenings to seniors at the annual Senior Health Fair.  Also collaborating with other health care providers to offer free services such as prescription education, blood pressure screening, hearing screening, stress relief, etc during the annual Senior Health Fair.

√  Publishing articles in the local newspaper promoting healthy living and “Eat Smart Move More North Carolina” programs.

√  Collaborating with Madison County Health Department to offer Diabetes Education Classes

 

 

 

 

 

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Tracking Progress of Health Priorities  (cont)

 

 

Priority-  Child Health Concerns

Progress

► Consortium Objective:

Reduce the percent of children who are overweight or obese by 5%.

 

The Healthy People 2010 Objective is to reduce the percent of children who are overweight or obese.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

► Consortium Objective:

Increase the awareness of positive parenting behavior and techniques.

 

The Healthy People 2010 Objective is to reduce the rate of repeat substantiated maltreatment reports (abuse and neglect) of children.

 

 

√  Collecting  height/weight/BMI data for all school children Kindergarten through 8th Grade yearly since 2008.

√  Promoting Cooperative Extension nutrition program “Steps for Health” which educates 3rd grade children and their families about healthy nutrition choices.

√  Promoting low cost/no cost physical activity opportunities for school age children during the summer months through the Madison County Parks and Recreation Department to offer “Terrific Tuesdays and Thursdays”. Program expanded in 2009 to include Wednesday activities specific for middle school age students.

 √  Promoting services of the newly opened school-based health center, Patriot Place, at Madison Middle School, which plans to offer nutrition counseling to students and families.

 

 

√  Working with other community agencies such as mental health agencies and the Department of Social Services to promote opportunities for positive parenting education. 

√ Collaborating with the health department to offer childbirth and parenting classes free of charge.

√  Utilizing consortium membership to increase awareness among public officials and the community about child abuse and neglect concerns.

√  Collaborating with Madison County Health Department on a multi-media child abuse prevention and awareness campaign.

 

 

 

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Tracking Progress of Health Priorities (cont)

 

Priority-  Mental Health Issues

Progress

► Consortium Objective: Increase the proportion of adults with mental illnesses who receive treatment.

 

The Healthy People 2010 Objective is to increase the proportion of adults with mental illnesses who receive treatment.

√  Organizing quarterly community Mental Health Forums in the areas of Mental Health/Substance Abuse/Developmental Disabilities to share information, collaborate among providers, and identify service gaps, etc.

√ Publishing articles in the local newspaper to  increase community awareness of access and updates to Mental Health/Substance Abuse services during current changing environment.

√  Promoting the “Telepsychiatry Program” at Madison County Health Department in efforts to address service provider gaps.

√  Partnering with the Madison County Health Department to offer mental health/behavioral health services to children and families through new school based health center at Madison Middle School.

 √  Promoting Families Together Mobile Crisis Management Program, a  service for children and adults in Madison County which provides 24/7/365 on call, telephone, and/or face to face crisis support.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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New Initiatives

 

Dental Center-  The Madison County Health Department received a grant from the North Carolina Health and Wellness Trust Fund for $100,000 a year for three years to offset revenue losses related to offering a sliding fee scale for patients that is based on Federal Poverty Guidelines.  Patients with incomes 40% of poverty and lower receive dental care and treatment with grant funding supplementing the discounted charges.  In its first year of operation, the dental center has seen over 600 patients, children and adults.  Patients from adjoining counties may access the sliding fee program also.

 

Tobacco Free… For Life! Program

The objective of the Tobacco Free…For Life! Program is to initiate a Tobacco Awareness and Prevention initiative in Madison County by educating 8th grade students on the harmful effects of tobacco products.  Madison County’s incidence and mortality rates for lung cancer are significantly higher when compared with Western North Carolina regional rates and state rates.  Thjs program will be implemented through the Healthy Living class period annually through curriculum format that includes a power point presentation, anatomical chart references with lung and interactive model which provides a visual demonstration of the dangerous effects of smoking.  Grant funds from the American Cancer Society Rural Health Initiatives Grant Program were received by the Madison Community Health Consortium to implement the program goals which include:  education on harmful effects of tobacco products and second hand smoke, promoting tobacco abstinence, and increase awareness of advocacy efforts in North Carolina.

 

Active Aging

Active Aging Week promotes the benefits of a healthy lifestyle by giving older adults the opportunity to experience activities and exercise in a safe, friendly, and fun atmosphere.  Active Aging Week is the annual health promotions event organized by the International Council on Active Aging, an association that supports professionals who develop wellness and fitness facilities and services for adults over 50 years of age and is held each year during the last full week of September.  Events are delivered by ICAA’s members and colleagues.  Land of Sky Council, Area Agency on Aging, Madison County Health Department, and the Madison Community Health Consortium collaborate to implement Active Aging Week.  Older adults have the opportunity to experience a variety of free activities that benefit health and well-being from Madison County providers who offer options for physical, emotional, creative, and intellectual activities during the week.   Partners in Madison County include:  Madison Community Services, New Image Fitness Center, Mars Hill Retirement Center, Mars Hill College, Madison County Library, Madison County Wellness Center, A-B Technical College, community centers and churches. 

 

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New Initiatives (cont)

 

Madison County Cancer Collaborative

The Madison County Cancer Collaborative Committee formed in October 2009 to discuss cancer disparities in Madison County and to identify some community solutions.  Incidence and mortality rates for lung cancer and breast cancer are much higher compared to the state and the nation.  Initially, members have decided to focus on faith-based initiatives.  Committee membership includes:  Hot Springs Health Program, Madison County Health Department, American Cancer Society, Relay for Life, Madison Community Health Consortium, Breast Cancer survivors, and community/faith representation.

 

Adolescent Positive Self-Esteem Program

The Adolescent Positive Self-Esteem Program mission is to equip adolescents with skills and knowledge to prevent or overcome poor self-esteem and accept who they are based on self-worth, self-confidence, and self-advocacy.  Positive self-esteem empowers adolescents to become successful academically and socially, thus leading to adult life success.  Led by public health nurses and in collaboration with school health nurses, presentations are made to all 5th grade boys and girls on an annual basis.

 

School Based Health Center-  Patriot Place Health Center opened its doors on September 18, 2009.  The center offers medical care, preventive care with comprehensive health assessments, behavior risk assessments, and behavioral/mental health counseling for students and families.  Staffed by a nurse practitioner, registered nurse, child psychologist, and administrative assistant, the center serves students attending Madison Middle School and Brush Creek Elementary School.

 

Inadequate Building Space-  The health department relocated into a more modern facility in 2007.  While the new location has much to offer, the health department has seen an increase in patients and service delivery.  There are two examination rooms for patients and one room for interviewing patients.  This limits the number of patients that can be seen during clinic hours and often increases the waiting time for services.  Lack of space also limits the ability to initiate new programs for the community.  Future effort will be given to the identification of outside funding to increase square footage.

 

 

 

 

 

 

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New Initiatives (cont)

 

Diabetes Self Management Program

In Spring 2009, the Madison County Health Department was selected to participate in the North Carolina Diabetes Education Recognition Program.  The program offers patients with diabetes information about monitoring blood sugar, meal planning, medications, disease complications, sick care, exercise and stress management.  Scheduled to become certified in 2010 by the American Dietetic Association, the program begins with an initial assessment and group class with follow-up.  It is led by two public health nurses and available to county residents.

 

ServSafe Program

The ServSafe food safety training program is one of the strongest education tools administered by the Nation Restaurant Association Educational Foundation.  ServSafe is recognized by more federal, state and local health jurisdictions than any other food safety training program in the United States.  Class participants are trained, tested and certified through the ServSafe Food Certification Course.  Participants learn about potentially hazardous foods and safe food handling practices, the system for food safety, establishing food safety standards and procedures, designing facilities, selecting appropriate equipment and how to work with regulatory agencies.  The Madison County Health Department has two instructors and plans are being developed to offer the course in 2010.

 

H1N1 and Public Health Preparedness

In April 2009, a national public health emergency was declared as a result of the detection of individuals infected by a swine-origin Influenza A virus, now known as pandemic (H1N1) 2009 virus.  Funding was appropriated to prepare for and respond to an influenza pandemic.  Staff at the Madison County Health Department is working to implement plans and activities to respond to pandemic outbreaks and mass vaccination efforts.

 

“Do All You Can To Prevent Child Abuse”

This is a two year project to implement community education and outreach in order to address the high rate of substantiated child abuse and neglect in the county.  Mass community education, parenting education classes, and enhanced home visits for teen mothers will be offered through a health educator at the Madison County Health Department and with collaboration from the child health committee of the Madison Community Health Consortium.

 

 

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New Initiatives (cont)

 

 

Fields of Hope Community Garden

Fields of Hope is a community garden that was started in 2007.  The garden helps feed local families by distributing the produce through partnerships with MANNA Food Bank, Asheville-Buncombe Christian Ministries, My Sister’s Place, The Beacon of Hope, Madison County Housing Authority and the Salvation Army of Madison County.  In 2008, over 50 volunteers worked to produce and harvest 42,000 pounds of vegetables and in 2009, nearly 700 volunteers helped to harvest 91,000 pounds of vegetables

 

Back Pack Program for Madison County Schools

Over 50% of Madison County school children receive free or reduced meals at school.  As a result of this high rate, the Back Pack Program was implemented in 2008 to provide children and their families bags of food for the weekend.  In 2008-2009, 109 students from four elementary schools were served.  Currently, there are 142 students receiving back packs with food each weekend.

 

MANNA’s Summer Feeding Pilot program

During the summer of 2009, nearly 5500 free meals were served to children ages

18 years and younger through the MANNA Food Bank Summer Feeding Program.  Sites included Ivy Ridge Apartments, Walnut Creek Apartments, French Broad Circle Apartments, Madison Middle School Jump Start Program, Madison County Parks and Recreation, Beech Glen Baptist Church, Mars Hill Recreational Park Pool, and the

W.T. Whitten Community Center.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Emerging Issues

 

 

Smoke-Free Restaurants

Beginning January 2, 2010, enclosed areas of almost all bars and restaurants must be smoke-free.  Under the new law, smoking will not be allowed in most enclosed areas of lodging establishments, such as hotels, motels, and inns, if the establishment prepares and serves food or drink.  The smoke-free law requires restaurant owners to post the required “no smoking” signs, remove indoor ashtrays and other receptacles, and direct any person who is smoking to extinguish the tobacco item.   Restaurant owners can contact law enforcement and a citation will be issued for any non-compliant customers.  The local health director is responsible for enforcing the law for any restaurant failing to comply.  Health educators and nurses are working to inform owners of the new law as time nears for implementation.

 

Funding Decreases-  State and federal budget shortfalls directly impact the delivery of local public health services.  With an uncertain economy, funding for public health programs and services are expected to decrease at the same time community needs for services increase.  Needs for local public health services will increase if more patients face unemployment and/or loss of insurance.  Management within the health department and county government continue to face difficult fiscal decisions while assuring the provision of health care services in the community.  In addition, state and federal program expectations for local health departments increase with no additional funding to the local agency.  It will be critical for public health to pursue third party reimbursement payers for increased revenues.

 

Graying Population-  Nearly 16% of county residents are 65 years of age and older.  This rate is higher than the state (12%) and other rural North Carolina counties (13.5%).  Population projections through the year 2020 indicate an additional 4.6% county increase compared to a 3% state increase in this age group.  Special consideration will need to be given to enhancing health promotion/disease prevention programs for this graying population.  According to the North Carolina Division of Aging, nearly 26% of Madison County adults over 65 years of age have two or more disabilities.  The poverty rates for older adults in Madison County are also greater than the state rates, with 19.2% living in poverty compared to a state rate of 13.2%.  With limited incomes, many older adults may opt to forego medical, dental and prescription needs in order to make ends meet.

 

 

 

 

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Emerging Issues (cont)

 

 

Health Check Coordination

The Health Check Coordinator position will no longer be funded after January 2010.  The coordinator’s responsibility is to assure children with Health Check/Health Choice receive timely well child examinations and immunizations.  Rates in Madison County have been low in previous years resulting in losses in funding by the Madison County Partnership for Smart Start.  Improvement in rates was expected with the addition of this position at the health department in 2009.  Unfortunately, health promotion and prevention outreach to children and families will cease through this specific program and the health department will have to increase outreach efforts through other programs.

 

Child Obesity-  Obesity is a serious health concern for children and adolescents.  Obese children and adolescents are at risk for health problems during their youth and as adults such as coronary heart disease, diabetes, cancer, high blood pressure, stroke, respiratory problems and more.  In 2006, the percent of overweight children up to

21 years of age was 19.7%, compared to the state 17%.  The health department and the school system conducted school health screenings in 2008-2009 that included baseline data for height, weight and BMI for children in Kindergarten through 8th grade. 

Twenty-six percent of 990 Madison County children in elementary school were identified as overweight, while 17% were at risk for overweight.  Data for the 2009-2010 school year will be available in Spring 2010.  Community solutions are needed for this community problem and this data will be helpful in future program development and intervention strategies.

 

Limited Physical Fitness Opportunities-  As a small rural county, physical fitness activities are limited at best.  There are few sidewalks and bike paths, one community swimming pool, and two small fitness centers.  Youth league team sports are organized within the individual communities who are required to find sponsorship and manage the facilities.  The Madison County Parks and Recreation Department is small, staffed by two persons and few resources to access.  Transportation and low income factors can have a negative impact on participation rates.  Fitness opportunities for adults are also limited and can be costly.  Child obesity must be considered as the community incorporates intervention strategies. 

 

 

 

 

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Emerging Issues (cont)

 

 

Mental Health Services

Community mental health services have suffered major state program funding cuts   forcing a turnover in local providers offering mental health and substance abuse to uninsured clients.  Case managers are no longer available to assist patients with treatment regimens.  In addition, the Department of Social Services and the public school system must absorb many who are no longer in case management programs.

Maintaining continuity of services for Madison County residents is in jeopardy as providers adapt to the limited funding.  The mental health committee of the Madison Community Health Consortium has played an important role in promoting dialogue between area mental health providers to identify community issues and concerns needing to be addressed.  With continued state budget woes, fiscal year 2010-2011 offers little hope for improvement.  The community must combine resources to help in meeting this critical need.

 

2010 Census

The U.S. Census counts every resident in the United States, and is required by the Constitution to take place every 10 years.  Accurate data reflects changes in our community and helps identify what resources the community will need for the coming years. 

The 2010 Census will help communities receive more than $400 billion in federal funds each year for:

  • Hospitals
  • Job training centers
  • Schools
  • Senior centers
  • Bridges, tunnels and other-public works projects
  • Emergency services

The 2010 census will help Madison County to identify population changes and support decisions about community services and programs.  The information from the census is vital to county departments and it is very important that the data is accurate and complete.  Residents will be encouraged to “be counted”.

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