Community Assessment

Part I: Community Assessment and Analysis

Hunterdon County, New Jersey

Amy Beddow, RN., Sherry Byk, RNC., Amber Walker RN., and
Teri Zimowski RN.

Grand Canyon University: NRS-427V-0105 Concepts in Community Health
October 27, 2013

INTRODUCTION

Hunterdon County, New Jersey has a vast array of community dynamics that are team has researched. Hunterdon County is the 18th most populated county in the state of New Jersey out of 21 counties. They have a population of 127,060 people with a median income of $100,980 (HCCC, 2013). Even with Hunterdon County being an affluent community consisting of the average age of a predominantly white population is
43.5 years old. Even with many social resources and the community cohesiveness that rural Hunterdon County prides itself as, 4% of its residents live in poverty. Although these statistics make Hunterdon County appear as an affluent community, there is still a state of poverty among vulnerable residents such as the Hispanics, elderly, and the mentally disabled to name a few. As a result of these stressors and barriers strewn throughout the community, health limitations and deficits are noted. The functional health patterns of Hunterdon County will be furthered discussed and dissected in the following paragraphs. .
SELF-PERCEPTION/ SELF-CONCEPT
The history of Hunterdon County is very interesting and stretches back to 12,000B.C. Paleo Indians moved into Hunterdon County between 12,000 BC and 11,000 BC. Paleo Indians traveled in small groups in search of game and edible plants. Native Americans moved into the area but the time they arrived is unknown. Most have come from the Mississippi River area. Many tribes of the Delaware Nation lived in Hunterdon County especially along the Delaware River and in the Flemington area. These tribes were agriculture in nature, growing corn, beans and squash. Those that lived along the South Branch of the Raritan River fished and farmed. There was a Native American trail that went along the South Branch of the Raritan River. Land purchases from Native Americans occurred from 1688 to 1758. Large land purchases from Native Americans occurred in 1703, 1709 and 1710 (Snyder, 2012). Over 150,000 acres were bought with metal knives and pots, clothing, blankets, barrels of rum or hard cider, guns, powder and shot. This allowed for European settlers to enter into Hunterdon County in the early 18th century. After 1760 nearly all Native Americans left New Jersey and relocated to eastern Canada or the Mississippi River area. The first European settlers were Col. John Reading who settled in Reading Township in 1704 and John Holcombe who settled in Lambertville in 1705. Hunterdon County was named for Robert Hunter, a colonial governor of New Jersey, through a corruption of Hunterston, his former home in England. Transitioning from rural to suburban, Hunterdon County is an exurb on the western edge of New Jersey and home to commuters to New York City and Philadelphia. The county seat, Flemington, is noted as the site of the Lindbergh kidnapping trial which convicted Bruno Hauptmann of the murder of aviator Charles Lindbergh 's son (Snyder, 2012). With growing towns and shopping areas, as well as relaxing rural areas, Hunterdon County is a far stretch from the urban areas stereotypically associated with New Jersey.

Hunterdon County, New Jersey has geopolitical borders. The borders are Mercer County Somerset County, Morris County, Warren County and Bucks County, Pennsylvania.

Hunterdon County has a larger proportion of residents aged 45-64 years compared to NJ. Increasing elderly (65 years and above) population. The proportion of children (under 18 years), adults (18-64 years) and elderly (65 years and over) residing in Hunterdon is relatively similar to that of New Jersey and the rest of the country. The similarity does not end there. As seen in all parts of the country, some more than others, the proportion and number of elderly are growing. And this is a trend that is expected to continue. “According to the Pew Research Center, there will be an average of 10,000 individuals celebrating their 65th birthday every day until 2030. Hunterdon County, the percentage of elderly rose from 10% in 2000 to 12.7% in 2010. In addition, the percentage of adults aged 45-64 years is much higher than the state average, 34.6% and 27.6%, respectively. It is projected that by 2030, elderly, aged 65 years and over will make up over 24% of Hunterdon’s population.” (Chua, 2013). Median age of residents in 2010: Median age for: White residents: 44 years old, Black residents: 28 years old, American Indian residents: 30 years old, Asian residents: 38 years old, Hispanic or Latino residents: 28 years old,
Other race residents: 26 years old (City-Data, 2013).

One of the interest of the community is the Hunterdon County Senior Center. It provides an outlet for County Seniors to remain active and assist them in enhancing their physical and mental well-being through various recreation and education activities (THCSC, 2013).
It is obvious that Hunterdon County residents enjoy engaging in recreational activities. The statistical data was equivalent to state wide, and only 2% difference nationwide with having recreational facilities accessible. The rate was 14 facilities per 100,000 people in Hunterdon County compared to New Jersey overall having 14 per 100,000 and National having 16 (90% percentile). This measure represents the number of recreational facilities per 100,000 population in a given county. Recreational facilities are defined as establishments primarily engaged in operating fitness and recreational sports facilities, featuring exercise and other active physical fitness conditioning or recreational sports activities such as swimming, skating, or racquet sports (CHRNJ, 2013). Health of residents in Hunterdon County based on CDC Behavioral Risk Factor Surveillance System Survey Questionnaires from 2003 to 2009 had a general health status score from 1 (poor) to 5 (excellent) was 3.8. This is significantly better than average. 79.9% of residents exercised in the past month.
Other activities the community is interested in is soccer. There are many school teams that play soccer and the community has interest in following these games. The community also has interest in the 4H clubs, VFW, Farmers’ Marker, hiking, camping, nature walks, parks, balloon festival, wineries, historic mills, equestarian activities, semi pro baseball and other sports. Points of interest include: Beneduce Vineyards, Hunterdon County Arboretum, Hunterdon County Art Museum, Hunterdon County Courthouse, Hunterdon Medical Center, Mount Salem Vineyards, Old York Cellars, and The Red Mill. Other popular activities are hunting and fishing. Hunterdon County is considered the premier place to hunt white tailed deer in New Jersey. “More deer are harvested each year than any other county according to New Jersey Fish and Game records. The premier fishing streams are the Musconetcong in the north and the Lamington River. The NJ Fish and Game stocks thousands of rainbow, brown, and brook trout in these streams as well as other streams such as the South Branch of the Raritan River. There is also Round Valley Reservoir and Spruce Run Reservoir for trout fishing as well as bass. Round Valley Reservoir which is manmade has lake trout in it. New Jersey Fish and Game has also many Wildlife Management Areas for hunting ducks, deer, pheasants, quail, rabbits, squirrels and bears” (Wikipedia, 2013).

VALUE/BELIEF PATTERN

New Jersey is one of the most diverse states in the country. However, diversity is not spread uniformly throughout the state. Hunterdon is made up of predominantly white, non-Hispanic residents (87.7%), a much higher proportion than NJ (59.3%). However, the county has seen tremendous growth in the number of people of a different race/ethnicity in recent years. The Hispanic community in particular, regardless of race, has increased by almost 200% in the past decade, from 2.8% in 2000 to 5.2% in 2010. Asians are the 3rd largest race/ethnic group in Hunterdon and makes up 3.2% of the county population, increasing from 1.2% in 2000 (Wikipedia, 2013).

The ability of service providers to effectively and appropriately communicate with the community they serve is vital. Language and differences in cultural norms, beliefs and attitudes, especially about health, can act as barriers to accessing health and social services, and will necessitate increased awareness, understanding and sensitivity of these differences among service providers. The increasing diversity affects the primary language spoken at home. Although much lower than the state average of 12.1%, the Limited English Proficiency (LEP) population in the county has increased from 2.2% in 2000 to 4.1% in 2010. Spanish (4.3%) is the second most common language spoken at home, far behind English (88.9%). Among the LEP population, those speaking Spanish increased from 0.9% in 2000 to 1.9% in 2009 (Chua, 2013).

There is a diversity with spiritual beliefs that is demonstrated from the numerous denominational churches in Hunterdon County. The following is the break down of adherents per church; Catholics make up 67.9% , Presbyterian 7.7%, United Methodist 5.2%, Reformed Church of America 3.4%, Jewish 2.3%, Episcopal and Lutheran 2.3% and 2.1%, American Baptist and Assemblies of God 1.8% and 1.7% (City Data, 2013). Access to high quality education was also frequently cited by focus group participants as one of the main strengths and appeal of the county. Students in private schools in grades 1 to 8 are 6.8% compared to New Jersey at 13.2%, from grade 9 to 12 was 19.2% compared to New Jersey 13.0%, and private undergraduate colleges 26.0% compared to New Jersey 30.1% (City-Data, 2013). Larger proportion of residents have a college or graduate/professional degrees (48%) compared to NJ overall. Hunterdon County residents age 25 years and older have high educational attainment with very little variation across the 26 municipalities. The municipalities of Union (78.3%) and Flemington (84%) have the lowest percentage of the adults 25 years or older who have a high school diploma or higher. A higher percentage of Hunterdon County residents graduated from college and/or obtained postsecondary education when compared to NJ as a whole, 48% and 34.5%, respectively (Chua, 2013). Raritan Valley Community College and Rutgers University offer continuing education in Hunterdon County.
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The community values and factors contributing to quality of life are 1) Rural Character –parks, open spaces, and other natural resources enhance the beauty of the county while encouraging physical activity by providing opportunity to engage in various outdoor recreation activities. 2) Safety of the Community –safety and low crime rate as factors that draw a lot of people to choose to live and raise a family in Hunterdon. 3) Excellent School System – Access to high quality education is one of the main strengths and appeal of the county 4) Strong Civic Support and Engagement –volunteerism and community support in the county is very strong. Community members and local businesses not only donate money, “but more importantly they volunteer their time, knowledge and expertise.” (City-Data, 2012).

It is evident that the community value health promotion as evidenced by self-help groups such as Athritis Support Group, Bariatric Support Group, Take Off Pounds Sensibly (TOPS) and an Ostomy Support Group.
Hunterdon Medical Center (HMC) is the only hospital in the community. They offer a wide variety of community services and support. They run a “baby fair” in April each year bringing resources and free advice and direction to the community members with infants and small children. They also have a free Heart Healthy campaign and Diabetes education center for those that need guidance, support or diagnosis. For childhood speech, behavior or learning disabilities HMC has an early intervention program which helps a parent navigate through the process of getting a child tested, diagnosis, and further help in the home or transition to school. Throughout the month on a rotating basis, HMC offers numerous classes or informational periods to address needs of all people in the community; bariatric, diabetes, new mom, stress, loss of family, Alcoholic Anomynous, Varicose vein cause and treatment, and many more. They can be found on the Hunterdon Medical Center
website.

HEALTH PERCEPTION/MANAGEMENT

Hunterdon County, New Jersey, was named the healthiest county out of 21 in the state of New Jersey based on the Robert Wood Johnson Foundation health outcomes. Hunterdon county rates number 3 for adult smoking, 14% compared to New Jersey being 16%. The number of diseases reported to public health nursing in Hunterdon County in 2012 was 1,812. This was no significant increase or decrease from the previous years of 201 and 2011. Tick borne disease was 1,333 of that 1,812 (Hunterdon County, 2012). This high occurrence can be related to the vast forest, park and extracurricular activity of hiking, fishing, running, etc. Hepatitis C accounted for 153 cases of disease.

Top reported causes of death were cancer, diseases of the heart and cerebrovascular diseases/stroke, although mortality rates due to these diseases were lower than NJ’s rates. Breast and prostate cancers, followed by melanomas of the skin were the most common types of cancer. Lung/bronchus, prostate and colon/rectum cancers were the most frequently reported causes of cancer deaths (Wikipedia, 2012).

HEALTH PERCEPTION/MANAGEMENT

New Jersey was ranked 42nd in the United States in 2009 for vaccination rates in infants and toddlers receiving recommended immunizations for Polio, Hepatitis B, Mumps, Rubella, and Measles. The New Jersey Immunization Network (NJIN) was formed by physicians and public health officials in 2009 to prevent the reappearance of latent preventable diseases such as Measles, Pertussis. One of the reasons for this low rating nationwide may be attributed to parent’s fear of vaccinations causing Autism. Other reasons include access to health clinics, lack of insurance, and delaying immunizations until children are required by schools.

A goal of Hunterdon County is to expand Phillips Barber Family Health Center that’s been serving the community since 1972 (The Star Ledger, 2013). The plan is in addition to providing a new family health center some of the services that may be considered are sub-specialty medical care, physical therapy, laboratory services, physician resident training center, integrated medicine, health and wellness services, outpatient behavioral health community, art lobby display, community meeting space and community gardens (The Star Ledger, 2013).

Another goal of the community is a new cardiovascular center at Hunterdon Medical Center (HMC). It will be constructed above the hospitals existing 3 west wing, which will be directly accessible by elevator from the Emergency Department in order to better accommodate cardiac emergencies (The Star Ledger, 2013). The new construction will include: two new cardiac catheterization labs providing emergency coronary intervention, carotid and peripheral angioplasty; Cardiac critical care unit; 20 private patient rooms, expanded space for cardiac imaging and intervention and the creation of specialty clinics in congestive heart failure and stroke; and, state of the art cardiopulmonary rehabilitation services (The Star Ledger, 2013).
HMC is a 178-bed teaching hospital that treats over 8,600 in patients annually and has 292,000 outpatient visits per year. Its Emergency Department sees approximately 33,000 patients each year (Chua, 2013). Since opening its doors in 1953, HMC has focused on primary care and community wellness, and emphasized the importance of providing quality care while achieving a high level of patient satisfaction. This is reflected in its mission and vision statements.

While there is a projected shortage of primary care providers in NJ and the rest of the nation, Hunterdon is in a better shape, as its main focus has always been on primary care and preventive services. Hunterdon boasts a 687:1 ratio of population to primary care physicians (includes family medicine, internal medicine, pediatrics, and obstetrics/gynecology), substantially better than the state ratio of 919:1(Chua, 2013). This is believed to be one of the reasons why Hunterdon is ranked the healthiest county in NJ in 2012.

Prevention is as important as primary care to the community of Hunterdon County.
They also pointed out that the focus on preventive care has a positive impact on the community’s overall health and well-being. Early detection of cancer increases chances for successful treatment and therefore survival. Accessibility and affordability of these preventive services are important. In Hunterdon, percentages of reported use of preventive services are generally higher than the state average with the exception of men over 40 years receiving a Prostate-Specific Antigen test. Percentages of reported use of preventive services in Hunterdon are higher among women over 40 years of age receiving mammogram and adults over 50 (CHRNJ, 2012). Among
HEALTH PERCEPTION/MANAGEMENT

women 40 years and over, 80% received a mammogram in the past 2 years compared to the state average of 72%. Looking at women 50 years and over, 81% from Hunterdon received a mammogram in the past 2 years, essentially meeting the Healthy People 2020 target of 81%. Among adults 50 years and over, 68% of Hunterdon residents reported receiving a sigmoidoscopy or colonoscopy test compared to just 64% statewide (Chua, 2013).

Regarding dental care, “83.4% of residents visited a dentist within the past year. This is more than average” (City-Data, 2013). However, similar barriers to accessing medical care exist for accessing dental care – lack of insurance, high cost, lack of transportation and not knowing where to go for affordable services. Additional barriers do however exist, such as fear and/or apprehension which “8.2% of Hunterdon adults claimed to be the main reason for not visiting a dentist in the past year. However, cost is overwhelmingly the primary barrier for Hunterdon county residents (31.6%) and among Hunterdon Hispanics in particular (65.2%)” (Chua, 2013). And predictably, oral health problems disproportionately impact the more vulnerable populations – the poor, children, elderly and racial/ethnic minorities. In Hunterdon, access to dental care is even more limited to those with lower income and Hispanics. “Dental problems are more evident among the elderly. However, access is not as a big issue for them as 80.1% of the elderly in Hunterdon reported visiting the dentist in the past year” (Chua, 2013).

Common barriers to accessing healthcare include “high cost, lack of insurance coverage, lack of transportation and language difficulties” (Chua, 2013). All of these barriers, at varying levels, are present in Hunterdon County. Among the Hunterdon Hispanic community, “use of preventive services is not nearly as frequent. Hispanics are less likely to be screened for blood cholesterol and for breast and colorectal” (Chua, 2013). Again, not having access to these preventive or early diagnostic tests contribute to the poorer health status of the Hispanics in the community.

Access to quality care was mentioned frequently in focus group sessions to be one of the community’s strengths. In Hunterdon, “93.2% of its adult residents reported having some form of health insurance, be it health insurance, or prepaid plans such as HMOs or government plans such as Medicare or Medicaid. This is considerably higher than state and national averages, 87.2% and 84.7%, respectively (Chua, 2013). Among adult Hunterdon residents, “93.2% have some form of health insurance coverage compared to just 87.2% in NJ. However, only 37.9% of Hunterdon Hispanics have some form of health insurance coverage. “Larger percentage of Hunterdon Hispanics reported not having a primary care provider and cited cost as a major barrier to seeing a doctor compared to the general Hunterdon. Persons enrolled in hospital insurance and/or supplemental medical insurance (Medicare) in July 1, 2003 was 15,585. Population without health insurance coverage in 2000 was 8% and children under 18 without health insurance coverage in 2000 was 5%” (City-Data, 2012).

NUTRITION/METABOLIC

Hunterdon County has numerous dining options ranging from fast food such as pizza shops, drive thru Dunkin Donuts, McDonalds, Taco Bell, Diners and many more fast food chains, to sit down dining restaurants, sport bars, cafes, buffets and brunches. The cuisine available is Greek, Italian, Indian, Latin, Turkish, Kosher, Middle Eastern, Cuban and Chinese (HCR, 2013).

According to the 2012 County Health Rankings, 6% of Hunterdon County residents experienced both financial and geographical barriers to accessing healthy foods such as fresh fruits and vegetables. However, this data does not provide an accurate picture of the food environment in the county because it is based solely on the number of and distance to grocery stores. It does not include other venues where healthy food can be purchased such as local farms, which are very common in Hunterdon. Although places are far and transportation continues to be a challenge for some residents, and more work needs to be done to reduce the barriers to accessing these healthy foods, a majority of its residents have access to farm stands and farmers’ markets (Chua, 2013).

“Although percentage of overweight and/or obese adults in Hunterdon is lower than the state and nation, it has been increasing over the past 15 years” (Chua, 2013). In addition, being overweight or obese substantially increases risk of developing certain chronic diseases such as heart disease and diabetes. The adult obesity rate in Hunterdon County is 18.8% of the population compared to New Jersey with a 23.3% rate (City-Data, 2012).

There is a federally funded food stamp program to assist households to help add to their food budget and allowance and improve their nutritional status (HCD, 2013).

ELIMINATION/ (HEALTH CONCERNS)
The physical environment where we live, work and play affects our individual health and the health of the community. The quality of air we breathe is especially important as exposure to harmful air pollution, such as high ozone levels and fine particulate matter, has been linked to poor health outcomes. According to the 2012 County Health Rankings, there were 11 days in 2007 when the ozone level in Hunterdon was unhealthy. Although similar to the state’s average annual number of unhealthy air quality days due to ozone, this is much higher than the national benchmark of zero. In addition, there was 1 day in 2007 when air quality was unhealthy due to fine particulate matter, again more than the national benchmark of zero (Chua, 2013). The relationship between elevated air pollution, particularly fine particulate matter and ozone, and compromised health has been well documented. Negative consequences of ambient air pollution include decreased lung function, chronic bronchitis, asthma, and other adverse pulmonary effects. Hunterdon County had a fine particulate matter of 12.2 when compared with New Jersey having 11.6 rating (CHRNJ, 2013). A reason for this elevation could be attributed to the vast farms, there are 352 preserved farms, parks, and tree cover all attributing to allergens from numerous plant and flower pollen. Poor air quality is a persistent issue in the county, attributing it as one of the main reasons for the high prevalence and incidence of asthma in the county, especially among youths.
The Office of Environmental Health provides information, consultation, distribution of educational materials for Radon Testing. The Environmental Health Office works with the County Public Health Nursing and Education Office to investigate incidents of childhood lead poisoning. A complete environmental investigation is done to determine the source of the lead. “On April 22,2010 an new EPA rule came into effect that requires companies that perform renovation, repair and painting projects that disturb lead based paint in homes, child care facilities, and schools built before 1978 be certified by EPA. Renovators must be trained by an EPA accredited training provider and must follow specific work practices to prevent lead contamination” (HCDPS, 2013).
Water quality is equally important. Percentage of population exposed to water exceeding a violation limit during the past year in Hunterdon County was 5% compared to New Jersey being 7%. This measure represents the percentage of the population getting water from public water systems with at least one health-based violation during the reporting period. Health-based violations include Maximum Contaminant Level, Maximum Residual Disinfectant Level and Treatment Technique violations (CHRNJ, 2013).

Pesticide usage in Hunterdon County includes black fly and mosquito control. The community is not notified of pesticides used in controlling vectors for West Nile Virus, but Hunterdon County Division of Public Health Services Mosquito and Vector Control Program can be contacted with any questions (HC, 2013).

There is indoor plumbing including well water and city water. Septic systems and city sewage are available also depending on the location of the homes (City-Data, 2012).

Hunterdon County does have a noise ordinance with a Noise Control Officer that has the authority to enforce it. The ordinance applies to construction or demolition, limiting the time period from 7am to 6pm during the week, and 9am to 6pm on the weekend days (HC, 2013).

The Sheriff’s office in Hunterdon County offers programs for the community’s safety. Lifesaver and Child I.D. Program are two of them. Project Life Saver is a wrist band tracking system for people with Alzheimer’s disease and other mentally dysfunctional disorders. The Child I.D. Program was developed to meet the mandated child fingerprinting law. Fingerprints, photograph, and information of the child is entered into a database and the ID card is given to the parent. In the event the child becomes lost or stolen, the parent provides the card to law enforcement. Other community wide safety programs are also used such as; neighborhood watch, school safety, drug free school and park zones, cyber safety, child safety, teens at risk and substance abuse (HC, 2013).

ROLE/RELATIONSHIP

Larger percentage of high school students reported having been bullied on school property compared to NJ’s average (Chua, 2013).

ROLE/RELATIONSHIP

The county has a lot of available healthcare and social services available for all its residents, and in particular the more vulnerable population, such as the children, disabled, seniors, lower income and the growing Latino population (Chua, 2013).

The Hispanic population is one of the vulnerable populations in Hunterdon County. They “more than tripled over the last 30 years. They are expected to be the largest portion of population increase in the county” (The Star Ledger, 2012). “69% said their health status was very good or excellent, 42% said they health status was fair to poor. This is a large increase since 2010 when only 7.8% of the county said there health status was fair to poor” (The Star Ledger, 2012). “A little over one third of the county’s Hispanics reported not being able to see a doctor in the last year due to cost, compared to 5% of the residence surveyed in 2010. More than 31.3% of Hispanics indicated that they did not obtain health care due to language barriers” (The Star Ledger, 2012).

Disparity exists especially among the Hispanic community, the fastest growing ethnic group in the county. Only 37.2% of Hispanic adults living in Hunterdon County reported having some form of health insurance, substantially lower than the general population, which translates to reduced access to both preventive and treatment services.The lack of health insurance or being underinsured can severely impact an individual’s decision of whether or not to seek needed care. “Approximately 5% of Hunterdon County residents reported not seeing a doctor or receiving needed medical care due to cost. This is much lower than the state and national averages of 12.7% and 14.9%, respectively. However, among the Hispanic county residents surveyed, 34.9% reported not being able to see a doctor in the past year due to cost. This is 7 times greater than the general population surveyed, once again showing extreme disparity. In addition to financial barriers, 31.3% of Hispanics surveyed reported that they could not get needed health care in the past year because of language barriers (Chua, 2013). And not surprisingly, this problem was even more significant among Hispanics with less than a high school diploma compared to those with more education. This data illustrates the demand and need for more Spanish-speaking and culturally competent healthcare providers. Studies show that language barriers contribute to health disparities and result in poorer health conditions, less patient satisfaction and less utilization of preventive services while overutilizing emergency department services.
“Latino Health Disparities show there is a stark disparity in access to and utilization of healthcare services between the Hunterdon Latinos and the general Hunterdon 2013 Hunterdon Community Health Needs Assessment population” (City-Data, 2012). They are also more likely to have poorer health outcomes and exhibit more risky behaviors compared to the general Hunterdon population. Although there are more services and programs for Latinos now than before, it is still not enough to adequately meet their need. Language and cultural differences and low health literacy continue to be barriers in accessing needed healthcare services.
“Due to the rural nature of the county, transportation was considered by many to be a major barrier to accessing healthcare and social services for many residents, in particular the elderly, low-income and disabled” (City-Data, 2012). “The county has a lot of available healthcare and social services available for all its residents, and in particular the more vulnerable population,

such as the children, disabled, seniors, lower income and the growing Latino population” (Chua, 2013). The health disparity seen among the Hunterdon Hispanic community is a result of multiple factors mentioned above; healthcare affordability, language and cultural differences and the accessibility of services geared towards this population.

Because of the high demand for and profitability of drugs, gang activity is increasing in Hunterdon (City-Data, 2012). Gang activity should be closely monitored in the future. “There was a considerable jump in gang presence between 2007 having 5% and 2010 having 25% of municipalities with gang presence. This has been one of the priorities of the County Prosecutor who is taking proactive steps to ensure and maintain the safety of the Hunterdon community” (Chua, 2013).

The differing priorities of federal, state and local governments are creating confusion and affecting availability and accessibility of services and programs in the county. Focus on the federal level is prevention and public health. However, decreasing budget has led to shifting of priorities away from health and human services and decreasing funding and staffing of various public health services at the local level. “Hunterdon County is governed by a five-member Board of Chosen Freeholders. The members are elected at large on a staggered basis to serve three-year terms of office, with the three-year term of office starting and ending on January 1. The Freeholder Board is the center of legislative and administrative responsibility and, as such, performs a dual role. As legislators they draw up and adopt a budget, and in the role of administrators they are responsible for spending the funds they have appropriated. Hunterdon County is solidly Republican and elects some of the most conservative members of the New Jersey legislature. It has also provided big votes for independent conservative Third Party candidates opposing liberal Republicans, particularly in 1997, when 13% of county voters backed two conservative independent candidates against incumbent Governor Christine Todd Whitman” (City-Data, 2012).

Hunterdon County has a first responders program which trains first responders in bioterrism. A multidisciplinary team of specialists that create, develop, evaluate and implement action plans to help prevent, prepare for and respond to serious public health crises including emerging diseases, pandemic influenza, disease outbreaks, wide-scale natural events and terrorist attacks. "Fit testing" is one of the many initiatives undertaken by the Public Health Preparedness division. This rigorous protocol established by the U.S. Department of Labor, Occupational Safety & Health Administration (OSHA) requires careful examination of personal protective equipment to ensure that responders to emergencies have the safest level of defense possible” (HC, 2013).

ACTIVITY/EXERCISE

Public transportation options within the county are very limited, which makes it difficult for a significant segment of the community to engage in community activities and access services. This especially impacts the low-income, the elderly, the disabled and other individuals with transportation challenges. Although the county offers affordable transportation through the LINK, it requires a lot of planning to schedule a trip and offers very little flexibility and has a
ACTIVITY/EXERCISE

limited capacity. HART Commuter Information Services, a non-profit agency, has been educating the community and service providers about ways to maximize the resources currently in place and to minimize transportation challenges (Chua, 2013). The following statistics are number and percentage of people that used a particular transportation option in Hunterdon County: Drove a car alone: 51,474 (83%) Carpooled: 4,572 (7%) Bus or trolley bus: 569 (1%) Streetcar or trolley car: 2 (0%) Subway or elevated: 16 (0%) Railroad: 455 (1%) Taxi: 27 (0%) Motorcycle: 12 (0%) Bicycle: 111 (0%) Walked: 1,135 (2%) Other means: 321 (1%) Worked at home: 3,665 (6%) (City-Data, 2013).

“The Flemington area is the most dangerous place to ride a bicycle in Hunterdon, according to an analysis, Northern New Jersey’s Most Dangerous Roads for Biking, released on Dec. 18 by the Tri-State Transportation Campaign, a non-profit group. The report highlights that between 2001 and 2011 there were 19,551 bicycle crashes also involving vehicles in 13 northern New Jersey counties - Bergen, Essex, Hudson, Hunterdon, Mercer, Middlesex, Monmouth, Morris, Passaic, Somerset, Sussex, Union and Warren. Of these, 81 were fatal. Overall, Hunterdon is one of the safer places to ride. Hunterdon had a 1.06 average yearly crash rate per 10,000 residents during the 10-year-study period. Hunterdon ranked 12th of the 13 counties with 149 crashes on an average of 14 per year. The overall accident rate for the 13-county region was 2.84 per year” (Hunterdon County Democrat, 2012). COPING/STRESS
The overall crime rate, violent and non-violent, crimes has been slowly but steadily declining since 2007. Included among violent crimes are murder, rape robbery and aggravated assault. Non-violent crimes include burglary, larceny-theft, and motor vehicle theft. “Juvenile arrests are predominantly due to drug abuse violations (2.67 per 1,000 juveniles) and larceny-theft (1.24 per 1,000 juveniles). Among adults, the highest rates of arrests are due to driving under the influence (6.39 per 1,000 adults) and drug abuse violations (5.97 per 1,000 adults). Although Hunterdon is relatively safe and has a low overall crime rate of 2.27 per 1,000 population, the most common offenses resulting in arrest were related to substance use/abuse, both among youths and adults. Rate of arrests due to Driving Under the Influence are higher among juveniles and adults are higher in the county compared to state average” (Chua, 2013). “1,402 people are in state prisons, 1,168 people are in correctional facilities intended for juveniles, and 1,114 people are in local jails and other municipal confinement facilities” (City-Data, 2012).
Substance abuse and its high prevalence of co morbidity with mental illness continue to be a pervasive problem in Hunterdon. Increasing accessibility to treatment services for substance abuse and mental illness is imperative to meet the persistent need. Emphasis on prevention

COPING/STRESS efforts is also critical to curb this problem. ED visits and hospital admission rates for mental and behavioral conditions are also lower than statewide rates. However, “ED visits and hospital admissions for mental or behavioral health conditions increased from 2006 to 2010. Also, the rate of ED visits among Hunterdon children (10.1 per 1,000), is higher than that of the state as a whole (8.9 per 1,000)” (Chua, 2013). The breakdown for people living in quarters associated with mental or behavioral health is as follows: “272 people in mental (psychiatric) hospitals and psychiatric units in other hospitals,103 people in group homes intended for adults, 58 people in workers’ group living quarters and job corps centers, 50 people in other noninstitutional facilities and 25 people in residential treatment centers for adults” (City-Data, 2012). The rate for suicides was per 1,000,000 people from 2000 to 2006; 80.1. This is more than state average (City-Data, 2012). As with other communities, having services available and accessible to persons with disabilities is of utmost importance. “In 2009, the percentage of Hunterdon County residents with one or more disabilites is lower than the state average. Most common forms of disabilities are difficulties with independent living, mobility and cognitive function” (Chua, 2013).

This is the third year Hunterdon County has seen an increase in the poverty level. It’s not huge numbers, but supports the broader findings that poverty is out in the suburbs and families are really struggling. Percentage of individuals in Hunterdon living below poverty is lower than NJ. Once again there is variation across the county, with certain municipalities experiencing greater poverty compared to others. In Flemington for example, “16.1% of individuals are living in poverty, significantly higher than the state average of 9.4%. In Delaware Township on the other hand, only 0.7% of individuals are living in poverty. In addition, the percentage of Hunterdon County residents 65 years and older living below poverty decreased from 4.2% in 2000 to 3.4% in 2011. However, among children under 18 years, it increased from 2.1% to 4.3% during the same time period” (Chua, 2013).

There is a large low income population and income affects everything; access to care, proper nutrition, opportunities to participate in organized recreational activities, and many more. In Hunterdon there is a growing number of “hidden poor.” These are individuals or families who are now struggling to make ends meet, yet do not seek assistance because they are embarrassed or they do not know where to go. In spite of its general affluence, “3.6% of Hunterdon County residents are living in poverty, based on the Federal Poverty Level. Although this rate is substantially lower than the state and national average, it went up from 2.6% in 2000 to a 5-year estimate of 3.6% between 2007 and 2011. In addition, it is important to note that the poverty thresholds are updated for inflation but are not adjusted based on geographic location which influences cost of living” (Chua, 2013). In a location such as Hunterdon where cost of living is higher than average, the above numbers actually underestimate the level of poverty. Some statistics are “percentage of residents living in poverty in Hunterdon County in 2009 was 4.8% compared to New Jersey as a total of 9.4%. Residents with income below the poverty level in 2009 were 2.6% compared to New Jersey at 8.5%” (City-Data, 2012). Hunterdon County is still

COPING/STRESS

below the state average for poverty, but is evidence in a successful, affluent community, poverty still can exist and needs to be addressed.

Hunterdon County historical area-adjusted tornado activity is slightly below New Jersey state average. “It is 1.2 times below overall U.S. average. Hunterdon County-area historical earthquake activity is slightly above New Jersey state average. It is 82% smaller than the overall U.S. average” (City-Data, 2012). The history of natural disasters in New Jersey include “Hurricane Floyd on September 16, 1999, New Jersey Virus Threat on May 30, 2000, New Jersey Terrorist Attack Emergency Declaration on September 11, 2001, New Jersey Snowstorm on February 16, 2003, New Jersey Tropical Depression Ivan on September 18, 2004, New Jersey Severe Storms and Flooding on April 1, 2005, New Jersey Hurricane Katrina Evacuation on August 29, 2005 and New Jersey Severe Storms and Flooding on June 23, 2006” (City-Data, 2012).

The Hunterdon County Medical Reserve Corps (MRC) is “one of 24 MRC units in New Jersey — and one of 979 across America — formed to respond to local community needs during wide-scale public health emergencies. Nearly 209,000 volunteers serve in MRC units in all 50 states — plus Washington DC, Puerto Rico, and the U.S. Virgin Islands. The Hunterdon County MRC is a ready-to-go unit that can be dispatched quickly to public health emergencies anywhere in the county, providing service to a population of 130,000 residents. The unit includes health professionals, either practicing or retired, as well as non-medical volunteers. The host agency for MRC is the Hunterdon County Division of Public Safety” (HC, 2013).

COGNITIVE/PERCEPTUAL

The ability of service providers to effectively and appropriately communicate with the community they serve is vital. Language and differences in cultural norms, beliefs and attitudes, especially about health, can act as barriers to accessing health and social services, and will necessitate increased awareness, understanding and sensitivity of these differences among service providers. The increasing diversity affects the primary language spoken at home. “Although much lower than the state average of 12.1%, the Limited English Proficiency (LEP) population in the county has increased from 2.2% in 2000 to 4.1% in 2010. Spanish (4.3%) is the second most common language spoken at home, far behind English (88.9%). Among the LEP population, those speaking Spanish increased from 0.9% in 2000 to 1.9% in 2009” (Chua, 2013).

Hunterdon is known for its excellent public school system, with high school graduation rates higher than the state average.
The high educational attainment of both adults and youths in the county, is a key contributor to overall quality of life. “Studies have shown that educational attainment is strongly correlated with an individual’s health. It is suggested that better educated individuals are more likely to have access to healthcare and are more health literate. Therefore they have better health outcomes and are more likely to contribute positively to their community” (Chua, 2013). Students in private schools in grades 1 to 8 (elementary and middle school) is 1,034, in Hunterdon County is 6.8% compared to New Jersey at 13.2%
Students in private schools in grades 9 to 12 (high school) is 608, 9.2% in Hunterdon County, compared to 13.0% in the state. Students in private undergraduate colleges are 945, Hunterdon County 26.0% compared to 30.1% in New Jersey (City-Data,
2012).

“Larger proportion of residents have a college or graduate/professional degrees (48%) compared to NJ overall. Hunterdon County residents, ages 25 years and older, have high educational attainment with very little variation across the 26 municipalities. The municipalities of Union (78.3%) and Flemington (84%) have the lowest percentage of the adults 25 years or older who have a high school diploma or higher. A higher percentage of Hunterdon County residents graduated from college and/or obtained postsecondary education when compared to NJ as a whole, 48% and 34.5%, respectively” (Chua, 2013). Access to high quality education was also frequently cited by focus group participants as one of the main strengths and appeal of the county. Raritan Valley Community College is the two-year community college for both Hunterdon and Somerset County, one of a network of 19 county colleges state-wide. Founded in 1965, the school 's main campus is located in North Branch. Rutgers University has a partnership with Raritan Valley Community College which offers Bachelor degree completion programs at the North Branch campus (Wikipedia, 2013).

SEXUALITY/REPRODUCTIVE

Larger percentage of pregnant women receiving prenatal care in the first trimester compared to state average. However, percentage among Hunterdon Hispanics is significantly lower (Chua, 2013). The number of births declined to 3,999,386 in 2010, 3% less than 2009. The teen birth rate fell 10% to 34.2 births per 1,000. C section rates in Hunterdon Medical Center are 40.4% compared to the New Jersey state average in 2009 of 40 %.
“A total of 3,953,590 births were registered in the United States in 2011, down 1% from 2010. Births declined 1% for non-Hispanic white and non-Hispanic black women and 3% for Hispanic women from 2010 to 2011. The 2011 general fertility rate was the lowest ever reported for the United States, at 63.2 births per 1,000 women aged 15–44, a 1% decline from 2010. The total fertility rate declined 2%, to 1,894.5 births per 1,000 women in 2011. The birth rate for teenagers aged 15–19 dropped 8% from 2010 to 2011, to 31.3, another historic low for the United States. Rates fell for age groups 15–17 and 18–19, and for all population groups by race and Hispanic origin. Birth rates declined between 2010 and 2011 among women in their 20s (the 2011 rate for women aged 20–24 was a record low), were unchanged for women aged 30–34, and rose for women aged 35–44. The number of births and the birth rate for unmarried women fell in 2011 for the third consecutive year. The number of non-marital births declined 2%, to 1,607,773 in 2011, and the birth rate dropped 3%, to 46.0 per 1,000 unmarried women aged 15–44. The percentage of births to unmarried women was essentially stable at 40.7%. The mean age of mother at first birth rose again, to 25.6 years in 2011, up from 25.4 years in 2010, and 21.4 years in 1970. The 2011 U.S. cesarean delivery rate was unchanged from 2010 at 32.8%. The cesarean rate rose nearly 60% from 1996 to 2009, but declined slightly from 2009 to 2010. The preterm birth rate (less than 37 weeks) declined for the fifth straight year, to 11.73% of all births in 2011, down 2% from 2010 and 8% from the 2006 peak. Declines between 2010 and 2011 were reported for the largest race and Hispanic origin groups. The 2011 rate of low birthweight (less than 2,500 grams) was 8.10%, down slightly from 2010 (8.15%) and 2% lower than the 2006 high (8.26%). The 2011 twin birth rate was 33.2 per 1,000 total births, and was essentially unchanged from 2009 and 2010. The rate of twin births rose 76% from 1980 to 2009–2011. The triplet and higher-order multiple birth rate (triplet/+) also was essentially unchanged from 2010, at 137.0 per 100,000, but has declined 29% since 1998” (Martin, 2013).

Friendship Center for New Beginnings is a pregnancy clinic available to women in Hunterdon County that offers numerous resources. Friendship Center for New Beginnings (FCNB) is a Christian outreach ministry to single mothers which has a history of adapting successfully to the changing needs of single mothers in the community, since its foundation in 1983. Their mission is to “empower single parent families to reach their full potential as individuals. They offer clients from Hunterdon County, parenting education and material support items. They also are invited each year to local high school health fairs, at which several thousand students have the opportunity to visit their booth for healthy relationship education, which encourages them with current research on the “success sequence”: finish high school, (and preferably graduate from college) and save sex for marriage. Further, FCNB initiated a Community Marriage Policy, involving twenty-five local pastors who committed themselves to strengthening marriage, and lowering the percentage of divorces and separations by providing thorough premarital counseling, marriage enrichment seminars and small group activities, and offering help to couples in crisis, using FCNB’s comprehensive library – now being used extensively, and at no cost, by many churches and agencies in our neighborhood. The community benefits from this pro-active stance, as the majority of high schoolers now choose abstinence, marriages are strengthened, and those who are already single parent families become fulfilled and productive citizens (Friendship Center for New Beginnings, 2013).

SLEEP/REST

Adequate sleep is important to good health. People who do not get enough sleep or poor quality sleep has an increased risk for high blood pressure, heart disease, and other medical conditions. When a person is asleep the body produces important hormones. These important hormones help build muscle mass, fight infections, repair cells, and affects how the body uses energy. People who do not acquire adequate sleep are at a greater risk to be overweight/obese, develop diabetes, and crave foods high in calories and carbohydrate (NIH, 2013a). People who have difficulties fall asleep, staying asleep, or both are considered to have insomnia. Insomnia can be acute or chronic. Acute insomnia is usually brought on by pressure and stress. Chronic insomnia can last for months and is usually associated with other medical conditions (NIH, 2013b).

CONCLUSION

Hunterdon County, New Jersey is made up of all kinds of people. In its population of 127,060 people, the median income is over 100 thousand dollars, with only four percent of residents in poverty. This town is mostly made up of white Americans, followed by Hispanics and Asians. This county was founded by Indians and that’s how it began. The elderly population is growing each year. The median age is 44 years of age. English is the most commonly used language followed by Spanish. Most of the people living in Hunterdon County follow catholic religion; however, there are many different religions in this area which helps keep this area diverse. 48% of residents from this area have gotten a college degree, some of which came from private schools. Some great assets of this county include, great schools, low crime rate which helps bring people in to this area, rural character, and strong civic support. The community is growing from the medical field is getting larger and more improved. They are adding more support and growing their hospitals. Physician ratio to patients is 687:1 which is why this is one of the healthier areas to live in New Jersey. 83.4% of residents visit the dentist yearly, which is a very healthy statistic. The county has a lot of available healthcare and social services available for all its residents. The rate of having recreational activities was 14 facilities per 100,000 people. The residents seem very interested in sports and outside activities but soccer is the most known and played. There is not much public transportation in this area which can make it hard for the average person to get around if they do not have a vehicle. Overall, this county seems like a great place to live. The crime rates, poverty level and such are low making it seem like a safe place to live.

SUMMARY TABLE

VALUE/BELIEF PATTERN
Presbyterian, 5.2% United Methodist, 3.4%, Reformed Church of America, 2.3% Jewish, 2.3% Episcopal and Lutheran, 2.1%, American Baptist, and 1.8% Assemblies of God (City Data, 2013).
Largest population is 87.7% non-Hispanic, 5.2% of Hispanic, 3.2% Asian (Chua, 2013).
Languages spoke is 88.9% English, 4.3% Spanish (Chua, 2013).
Nursing diagnosis
1. Readiness for enhanced Spirituality r/t need of connections with others
2. Language barrier r/t interpreters need to be utilized with non-English speaking residents (Ackley & Ladwig, 2008).

HEALTH PERCEPTION/MANAGEMENT

• Hunterdon county report a higher usage of preventative services (CHRNJ, 2012).
• Higher rates of mammograms, colonoscopies, and prostate-specific antigen test (Chua, 2013).
• 83.4% of the population visits the dentist regularly (City-Data, 2013).
• Hunterdon County Senior Center provides many opportunities for seniors to remain active through numerous recreational and educational activities (THCSC, 2013).
• There are approximately 14 recreational facilities per 100,000 residents.
• Limited public transportation for the underprivileged to keep doctor appointments (Chua, 2013).
Nursing diagnosis
1. Health seeking behaviors r/t increased use of preventative and screening services.
2. Decreased activity intolerance r/t high number of recreational facilities (Ackley & Ladwig, 2008).

NUTRITION/METABOLIC
• Adult obesity rate is 18.8% (City Data, 2013).
• County residents on government assistance programs are lower that other counties (City Data, 2013).
Unemployment, poverty, low wages and high housing costs are the most common reasons for requesting food assistance (City Data, 2013).
Nursing Diagnosis
1. Imbalanced nutrition: more than body requires r/t adult obesity (Ackley & Ladwig, 2008).
2. Chronic low self-esteem r/t ineffective coping and overeating (Ackley & Ladwig, 2008).
Elimination (Environmental Health Concerns)
• Poor air quality. In 2007 there were 11 days when ozone level was unhealthy (Chua, 2013).
• In 2007 one day air quality was unhealthy due to fine particulate matter (Chua, 2013).
Nursing Diagnosis
1. Risk for injury r/t poor air environment (Ackley & Ladwig, 2008)
2. Risk for ineffective airway clearance r/t unhealthy air quality (Ackley & Ladwig, 2008).

Activity/Exercise
• 79.9% of residents exercise per month (City Data, 2013).
• 45.3% of residents have smoked cigarettes in their lives (City Data, 2013).
• 98.8% of adult residents have drank alcohol in the past month (City Data, 2013).
• Average weight of a male is 190lbs (City Data, 2013).
• Average weight of a female is 153lbs (City Data, 2013).
• Many limitation with public transportation making it difficult for a significant segment of the county (Chua, 2013).
• HART Commuter Information Services, a non-profit agency, has been educating ways to maximize transportation resources (Chua, 2013).
Nursing Diagnosis
1. Disturbed thought processes r/t consumption of alcohol (Ackley & Ladwig, 2008).
2. Ineffective community coping r/t need of increased public transportation (Ackley & Ladwig, 2008).
Cognitive/Perceptual
• 88.9% of residents speak English (Chua, 2013).
• 4.3% of residents speak Spanish (Chua, 2013).
• 48% of residents are college graduates (Chua, 2013).
• 34.5% of residents have a postsecondary education (Chua, 2013).
• Raritan Valley Community College and Rutgers University are part of this community (Chua, 2013).
Nursing Diagnosis
1. Ineffective Communication r/t language barriers (Ackley & Ladwig, 2008).
2. Readiness for enhanced knowledge r/t population with postsecondary education (Ackley & Ladwig, 2008).
Self-Perception/Self-Concept
• Largest age population is between the ages of 45-60. It is speculated that the 65 and older age group will continue to grow to 24% of the county population (Chua, 2013).
• The history of Hunterdon County stems from the American Indian Paleo Tribe (Snyder, 2012).
• Many residents commute to New York City and Philadelphia.

Nursing Diagnosis
1. Death anxiety r/t aging population (Ackley & Ladwig, 2008).
2. Risk for anxiety r/t long commutes for employment (Ackley & Ladwig, 2008).
Role Relationship
• Large percentage of high school students bullied compared to national average (Chua, 2013).
• Above average available healthcare for all residents including the vulnerable population (Chua, 2013).
• Hispanic population largest vulnerable population (Chua, 2013).
• Significant increase of gang activities, 25% of municipalities have gang presence (Chua, 2013).
Nursing Diagnosis
1. Ineffective health maintenance r/t vulnerable population without health insurance (Ackley & Ladwig, 2008)
2. Post-trauma syndrome r/t increased gang activity (Ackley & Ladwig, 2008).

Sexuality/Reproductive
• Friendship Center for New Beginnings is a pregnancy clinic for women (FCNB, 2013)
• This county has the largest percentage of women receiving prenatal care starting in the first trimester population (Chua, 2013).
• Birth rate for teenagers down 8% from previous year (Martin, 2013).
• Most recent birth rates are 82.05 per 100,000 (City Data, 2013).
Nursing Diagnosis
1. Decisional Conflict: sexual activity r/t decrease teenage births (Ackley & Ladwig, 2008).
2. Health seeking behaviors r/t increased population receiving prenatal care (Ackley & Ladwig, 2008).
Coping/Stress
• Noting the success-driven culture and competitive environment leads to stress and anxiety (City Data, 2013).
• Substance abuse is a prevalent issue in the county that cuts across age and gender barriers (City Data, 2013).
• 45.3% of residents smoked greater than 100 cigarettes in their lives (City Data, 2013).
• Adult arrests are primarily DUI’s and drug abuse violations (Chua, 2013).
• Juvenile arrests are predominantly due to drug abuse violations (Chua, 2013).
• Crime rate of 2.27 per 1000 population (Chua, 2013).

Nursing Diagnosis
1. Stress overload r/t success driven culture (Ackley & Ladwig, 2008).
2. Ineffective coping r/t substance abuse (Ackley & Ladwig, 2008).

Sleep/Rest
• Adequate sleep important to good health (NIH, 2013a).
• Lack of sleep put people at risk for high blood pressure, heart disease, and other medical conditions (NIH, 2013a).
• Insomnia is usually associated with other medical conditions (NIH, 2013b).
Nursing Diagnosis
1. Sleep Deprivation r/t prolonged periods without adequate sleep (Ackley & Ladwig, 2008).
2. Insomnia r/t increased life stressors (Ackley & Ladwig, 2008).

REFERENCES
Ackley, B., Ladwig, G. (2008). Nursing Diagnosis Handbook (8th ed). St. Louis, MI: Mosby Elsevier.

Chua, J. MPH, CHES., Hunterdon County Community Health Needs Assessment, June 28, 2013. Retrieved from: http://partnershipforhealth.hunterdonhealthcare.org/docs/2013%20HC_CHNA_Final.pdf
City-Data, Hunterdon County. 2013. Retrieved from: HTTP://www.city-data.com/county/Hunterdon_County-NJ.html
Friendship Center for New Beginnings, Website. 2013. Retrieved from: http://www.friendship-center.org/page2.html

Hunterdon County Division of Social Services (HCD). 2013. Programs and Services. Retrieved from http://co.hunterdon.nj.us/depts./social/socserv.html

Hunterdon County Division of Public Safety (HCDPS) 2013. retrieved from: http://www.co.hunterdon.nj.us/health/environmental/lead.html

Hunterdon County. (HC) Official Home Page. 2013. Retrieved from: http://co.hunterdon.nj.us/index.html

The Hunterdon County Senior Center (THCSC), 2013. Retrieved from: http://www.co.huterdon.nj/aging/seniorcenter.htm

Hunterdon County Chamber of Commerce. (HCCC). 2013. Retrieved from: http://www.hunterdon-chamber.org/

Hunterdon County Democrat, December 20, 2012. Study: Flemington area most dangerous place to cycle in Hunterdon. Retrieved from: http://www.nj.com/hunterdon-county-democrat/index.ssf/2012/12/study_flemington_area_most_dan.html
Hunterdon County Restaraunts (HCR). Places to Eat in Hunterdon County, NJ-dining out in New Jersey (2013). Retreived from: http://njrestaraunts.com/hunterdon.html

County Health Ratings in New Jersey (CHRNJ). 2013. Hunterdon County. Retrieved from: http://www.countyhealthrankings.org/app/new-jersey/2013/rankings/outcomes/overall/by-rank#/new-jersey/2013/compare-counties/019

Martin, J.A., Hamilton, B.E., Ventura, S.J., et al. Births: Final Data for 2011. National Vital Statistics Reports; vol. 62, no.1. Hyattsville, MD: National Center for Health Statistics. 2013.

New Jersey Demographics by Cubit. (NJDC), 2013. Retrieved from:http://www.newjersy-demographics.com/huterdon-couty-demographics.

National Institutes of Health (NIH) (2013a) At a Glance: Healthy Sleep [data file]. Retrieved from http://www.nhlbi.nih.gov/health/public/sleep/healthy_sleep_atglance.htm

National Institutes of Health (NIH) (2013b) What Is Insomnia? [data file]. Retrieved from http://www.nhlbi.nih.gov/health/health-topics/topics/inso/

Snyder, John P. The Story of New Jersey 's Civil Boundaries: 1606-1968, Bureau of Geology and Topography; Trenton, New Jersey; 1969. p.153. Accessed May 30, 2012

The Star Ledger. Hunterdon County health survey unveils issue unique to Latinos. Retrieved from: http://www.nj.com/hunderton-county-democrat/index.ssf/2012/06/hunterdon_county_hea

The Star Ledger. Hunterdon County announces plans to expand Phillips Barber Family Health Center.. Retrieved from: http://www.nj.com/hunderton-county-democrat/index.ssf/2013/10/hunterdon_healthcare

USA.Com. Hunterdon County. Retrieved from: http://usa.com/hunterdon-county-nj.htm.
Wikipedia. Hunterdon County. October 20, 2013. retrieved from: http://readtiger.com/wkp/en/Hunterdon_County,_New_Jersey#Hunting_and_fishing