- Eastern Shore - Community Health Needs Assessment

Transcription

1 - Eastern Shore - Community Health Needs Assessment The Community Health Needs Assessment for Adventist Behavioral Health Eastern Shore was approved by the Adventist HealthCare Board of Trustees on October 23, 2013

2 Table of Contents Section I. Introduction a. Adventist Behavioral Health Eastern Shore Overview b. The Community We Serve c. Demographics d. Income & Poverty e. Access to Care/Health Insurance Coverage Section II. Methodology a. Establishing Infrastructure and Selecting Priorities b. Collecting and Analyzing Data c. Primary Data Collection d. Partnerships e. Other Available Data f. Limitations and Data Gaps Identified Section III. Part a. Part b. Findings Disease Incidence and Prevalence Chapter 1: Behavioral Health Spotlight on Smoking/Tobacco Use Chapter 2: Cancer Overview: 2.1 Breast Cancer 2.2 Lung Cancer 2.3 Colorectal Cancer 2.4 Prostate Cancer 2.5 Cervical Cancer 2.6 Skin Cancer 2.7 Oral Cancer 2.8 Thyroid Cancer Chapter 3: Heart Disease and Stroke Chapter 4: Diabetes Chapter 5: Obesity Chapter 6: Asthma Chapter 7: Influenza Chapter 8. HIV/AIDS Spotlight on Sexually Transmitted Infections Population Health Chapter 9. Maternal and Infant Health Chapter 10. Senior Health Part c. Social Determinants of Health Chapter 11. Food Access Chapter 12. Housing Quality Spotlight on Homelessness Chapter 13. Education Chapter 14. Transportation 2

3 Section I. Introduction 3

4 Section I. Introduction a. Adventist Behavioral Health Eastern Shore Overview Adventist Behavioral Health Eastern Shore Adventist Behavioral Health Eastern Shore is a non-profit, Joint Commission accredited psychiatric treatment facility located in Dorchester County. Adventist Behavioral Health Eastern Shore is part of a network of health care facilities owned by Adventist HealthCare. Adventist HealthCare established the first behavioral health unit in Montgomery County in 1949 and remains one of the leading providers of mental healthcare in the Washington, DC metropolitan area. Since its inception, Adventist Behavioral Health has expanded to include several treatment centers across Montgomery, Anne Arundel, and Charles Counties, as well as the eastern shore of Maryland. Guided by a mission to deliver clinical and service excellence through a ministry of physical, mental and spiritual healing, Adventist Behavioral Health Eastern Shore provides services and treatment options for children and adolescents. Services are provided in a variety of settings including hospital-based programs, residential treatment centers, school programs, residential group homes, outpatient services and community-based services. Our facilities offer a highly-skilled, multidisciplinary team of psychiatrists, social workers, case managers, psychiatric nurses, expressive therapists and chaplains who provide compassionate behavioral healthcare. Acute Mental Health Services Adventist Behavioral Health Eastern Shore provides inpatient treatment for children, adolescents, adults and geriatric adults whose acute mental illnesses require immediate stabilization. The goal of the treatment program is to stabilize the patient through medication management, group therapy, family meetings, expressive therapy (art, movement and music) and pastoral care. The acute inpatient treatment team works closely with all patients and their family or caregivers to create an individualized treatment plan that emphasizes recovery and wellness. Adventist Behavioral Health s Eastern Shore inpatient treatment programs provide treatment for a range of mental and behavioral health illnesses, including: Schizophrenia Schizoaffective Disorder Mood Disorder PTSD Suicidal Ideations Bipolar Disorder Depression Violent and Aggressive Behavior Chronic Substance Abuse Trauma ADHD 4

5 Residential Treatment Center Adventist Behavioral Health s Eastern Shore Residential Treatment Center (RTC) offers psychiatric treatment for adolescents 12 to 18 years old who have a history of mental illness and severe emotional or behavioral challenges. Our residents are supported by a team of psychiatrists, nurses, social workers, and therapists who provide care and supervision 24-hours a day in a secure residential treatment environment. Residents who are admitted into the RTC program frequently display a pattern of disruptive behavior, which can include aggressiveness toward others, suicidal ideations, truancy, and selfinjurious behaviors such as cutting. The RTC program consists of daily, structured therapies, on-site special and general education services, and recreational and leisure activities that provide adolescents opportunities to assume responsibility for their behaviors, develop positive coping skills, explore values and learn effective communication techniques. Adventist Behavioral Health Eastern Shore also offers an RTC program for adolescent male sex offenders. The program helps diagnose and treat adolescent males with sexualized behavior problems. Directed by an internationally recognized expert on sexual trauma and perpetration in adolescents, the program helps adolescent males gain understanding and control over their sexual behavior and successfully return to community living. Available treatment and therapies include: Comprehensive behavioral health and substance abuse assessment On-site special and general education by Maryland State Department of Education-approved staff Equine therapy Expressive therapy (including art, music, and dance) Individual and group therapy Pastoral care Field trips (as clinically appropriate) Pet therapy Relapse prevention and aftercare transition Partial Hospital Program Adventist Behavioral Health s Eastern Shore Partial Hospitalization Programs for children, adolescents and adults bridge the gap between acute inpatient and outpatient services, serving as both an alternative to hospitalization and as a transition from inpatient care. The programs provide a structured, therapeutically intensive setting for individuals who do not require 24-hour supervision but still need a high degree of therapeutic support. Adventist Behavioral Health Eastern Shore offers Partial Hospitalization Programs with several specialized treatment tracks for individuals with substance abuse challenges, mood disorders, and self-destructive behaviors. Our programs also include a Transitional Youth track designed to help mentally ill adolescents transition into adulthood and 5

6 independent living. The Partial Hospitalization Program s interdisciplinary staff of psychiatrists, psychologists, social workers, expressive therapists and nurses provides a variety of group-based treatment approaches, including psycho-educational, psychodynamic and activity group therapy. Intensive Outpatient Program Adventist Behavioral Health s Eastern Shore Intensive Outpatient Treatment Programs for adolescents and adults provide a structured therapeutic treatment environment for individuals with mental illness or substance abuse challenges or both (also known as cooccurring disorders). The program is often utilized as a step-down from inpatient psychiatric care. Our facilities provide evening treatment sessions to enable patients to remain employed or in school during the day. The program focuses directly on the role of alcohol and drugs as they relate to negative feelings and behaviors. Our clinical program includes educating adolescents and adults on the disease of alcohol addiction and determining their stage of abuse/addiction; identifying psychosocial stressors that lead to substance abuse; treating the addiction following the 12-step model; providing drug and alcohol education; and providing relapse prevention education and treatment. Conditions and symptoms treated include: Mood Disorders Suicidal Ideations Violent and Aggressive Behavior Chronic Substance Abuse Self-destructive Behavior such as cutting or other high risk behavior b. The Community We Serve Adventist Behavioral Health Eastern Shore primarily serves residents of Wicomico County and Dorchester County, Maryland, which together account for 60 percent of patient discharges. Therefore, for the purpose of this Community Health Needs Assessment, we will focus on local data from Wicomico and Dorchester Counties. Below, Figure 1 shows the percentages of discharges by county for Adventist Behavioral Health Eastern Shore: County Percentage Wicomico 40% Dorchester 20% Worcester 8% Somerset 7% Talbot 7% Anne Arundel 7% Caroline 6% Other 5% Figure 1. Adventist Behavioral Health Eastern Shore s discharges by county,

7 Approximately 80 percent of discharges come from our Total Service Area, which is considered Adventist Behavioral Health Eastern Shore s Community Benefit Service Area CBSA (see Figure 2). Within that area, 60 percent of discharges are from the Primary Service Area, including the following ZIP codes/cities: Easton; Cambridge; Chestertown; Denton; Hurlock; 21801, Salisbury; Berlin; Fruitland; Princess Anne; Delmar (see Figure 2). We draw 20 percent of discharges from our Secondary Service Area including the following ZIP codes/cities: Edgewater; Crofton; Pasadena; Baltimore; 21401, 21403, Annapolis, Centreville; Grasonville; Greensboro; Henderson; Rhodesdale; Trappe; Crisfield; Hebron; Linkwood; Parsonsburg; Pocomoke City; Snow Hill (see Figure 2). Figure 2. Map of Adventist Behavioral Health Eastern Shore s Primary Service Area (purple) and Secondary Service Area (orange) based on 2011 inpatient discharges. 7

8 c. Demographics Our Community Benefit Service Area (CBSA), covering approximately 80 percent of discharges, includes 466,080 people from the racial/ethnic categories below, of which approximately 28.9 percent are minorities (see Figure 3). BLACK/ AF AMER 2011 Estimates NATIVE AMERICAN NATIVE HI/PI HISPANIC / LATINO WHITE ASIAN Community Benefit Service Area (CBSA) 331, , , % 22.8% 1.6% 0.3% 0.1% 4.2% Primary Service Area (PSA) 128,601 44, % 24.1% 1.5% 0.2% 0.1% 3.8% Secondary Service Area (SSA) 202,807 62, % 21.9% 1.6% 0.3% 0.1% 4.5% Figure 3. Population estimates (2011) by race/ethnicity for Adventist Behavioral Health Eastern Shore s Community Benefit Service Area (80 percent of discharges), Primary Service Area (60 percent of discharges) and Secondary Service Area (20 percent of discharges) Population demographics are rapidly changing in the state of Maryland, including among residents living in Wicomico County and Dorchester County. Agriculture is Wicomico County s main industry as the state s top agricultural county known for its Perdue farms, while Dorchester County s pristine rivers, marshlands, working boats, quaint waterfront towns and villages of fertile farm fields is known as the Heart of the Chesapeake Country. Over the past decade, the populations of Wicomico County and Dorchester County have continued to rise. Racial and ethnic diversity is also increasing in both counties. The minority population is 31.4 percent in Wicomico County, and 32.4 percent in Dorchester County, an increase of more than 5 percent over the last decade (U.S. Census, 2010). Blacks/African Americans comprise the highest percentage of all minority groups at 24.2 percent of the population of Wicomico County and 27.7 percent of the population of Dorchester County (see Figure 4) (U.S. Census, 2010). As racial and ethnic minority populations have increased, concerns regarding health disparities grow persistent and well-documented data indicate that racial and ethnic minorities still lag behind nonminority populations in many health outcomes measures. These groups are less likely to receive preventive care to stay healthy and are more likely to suffer from serious illnesses, such as cancer and heart disease. 8

9 Further exacerbating the problem is the fact that racial and ethnic minorities often have challenges accessing quality healthcare, either because they lack health insurance or because the communities in which they live are underserved by health professionals. As the proportion of racial and ethnic minority residents continues to grow, it will become even more important for the healthcare system to understand the unique characteristics of these populations in order to meet the health needs of the community as a whole. As a result, this report examines health status and outcomes among different racial and ethnic populations in Wicomico County and Dorchester County, with the goal of eliminating disparities, achieving health equity, and improving the health of all groups. In response to the changing demographic characteristics of the communities surrounding their hospitals, Adventist HealthCare the parent organization of Adventist Behavioral Health Eastern Shore has made cultural competence an organizational priority. Cultural competence refers to a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in crosscultural situations 'Competence' implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities. 1 In essence, cultural competence offers a means to treat patients the way they want to be treated it is the actualization of the platinum rule guiding how Adventist HealthCare aims to provide care. 1 Office of Minority Health. (2005). What is culturally competency? Retrieved October 8, 2011 from 9

10 Dorchester and Wicomico County Demographics: Demographics Wicomico Dorchester Maryland Total Population* 98,733 32,618 5,884,563 Age*, % Under 5 Years 6.9% 6.2% 6.3% Under 18 Years 23.3% 21.7% 23.4% 65 Years and Older 13.4% 17.7% 12.3 % Race/Ethnicity*, % White 66.6% 67.6% 58.2% Black 24.2% 27.7 % 29.4% Native American 0.2% 0.3% 0.4% Asian 2.5% 0.9% 5.5% Hispanic or Latino 4.5% 3.5% 8.2% origin Median Household $47,280 $46,710 $70,017 Income* Households in 12% 12.3% 8.6% Poverty**, % Pop. 25+ Without H.S. 14.9% 17.3% 12.1 Diploma**, % Pop. 25+ With Bachelor s Degree or Above**, % 24.5% 17.3% 35.6% Sources: * U.S. Census (2012), ** American Community Survey ( ) Figure 4. Dorchester and Wicomico Counties, MD Demographics (Accessed 2013: Life Expectancy by County within the CBSA: According to the 2012 Maryland State Health Improvement Process, the overall life expectancy for Maryland was 79.3 years old. The overall life expectancy for Wicomico County was 76.8 years old. Among black residents of Wicomico County, the life expectancy was 74.9 years old, compared to 77.4 years old among white residents of Wicomico County. In Dorchester County, the overall life expectancy was 77.2 years old in Among black residents of Dorchester County, the life expectancy was 72.9 years compared to 79.0 years old among white residents (see Figure 5). Figure 5. Life Expectancy at Birth, Wicomico County and Dorchester County, Maryland, U.S. (Source: Maryland SHIP) 10

11 Mortality Rates by County within the CBSA: The mortality rate in Wicomico County is per 100,000 population ( ). The mortality rate in Dorchester County is per 100,000 population ( ). Both of these mortality rates are higher than the mortality rate for the state of Maryland overall, at per 100,000 population. The rate of heart disease deaths per 100,000 population is higher in both Wicomico County (255.0 per 100,000) and in Dorchester County (198.5 per 100,000 population) than the rate of heart disease death statewide (182.0 per 100,000) (see Figure 6). Figure 6. Rate of Heart Disease Deaths, Wicomico County and Dorchester County, Maryland, U.S. (Source: Maryland SHIP) The infant mortality rate is much higher in Dorchester County (16.9 per 100,000 population) compared to the state of Maryland s rate (6.7 per 100,000 population) (see Figure 7). Figure 7. Infant Mortality Rate, by Race/Ethnicity, Wicomico and Dorchester County, Maryland, U.S. (Source: Maryland SHIP) 11

12 d. Income & Poverty The median household income within Adventist Behavioral Health Eastern Shore s CBSA is $57,034, which is significantly lower than the median income for the state of Maryland ($70,017), but higher than the median income in the nation ($50,221) (U.S. Census Bureau, ACS, 2011). Household income has a direct influence on a family s ability to pay for necessities, including health insurance and healthcare services. A wide body of research points to the fact that low-income individuals tend to experience worse health outcomes than wealthier individuals, clearly demonstrating that income disparities are tied to health disparities. Great income disparities exist when broken down by racial/ethnic groups. Throughout the CBSA served by Adventist Behavioral Health Eastern Shore, among racial and ethnic groups, non-hispanic whites and Asians have the highest median household incomes, while blacks and Hispanics are more likely to live in poverty (see Figure 8) (U.S. Census Bureau, ACS, 2011). White households in Dorchester County had a median household income of $52,614 and white households in Wicomico County had a median household income of $55,747, while Hispanic and black households had much lower median household incomes in both counties (see Figure 8) (U.S. Census Bureau, ACS, 2011). Income $100,000 $90,000 $80,000 $70,000 $60,000 $50,000 $40,000 $30,000 $20,000 $10,000 $0 Median Household Income All Maryland Dorchester County Wicomico County White Black Hispanic Asian Figure 8. Median Household Income, Wicomico County, Dorchester County, Maryland, by Race, (Source: Both Wicomico County and Dorchester County experienced poverty levels higher than the state of Maryland overall. According to the U.S. Census Bureau, between , Dorchester County had 12.3 percent of its population living in poverty, while Wicomico County had 12 percent of its population living in poverty. In 2010, across all counties in Maryland, more residents were living below the poverty level than in In 2006, 8 percent of Maryland residents lived in poverty and by 2010, just over 9 percent of people had income below the poverty line, representing a 15 percent increase in poverty (U.S. 12

13 Census Bureau, 2011). Across the state of Maryland, nearly a quarter of black residents had incomes less than 100 percent of the federal poverty level (FPL) in Approximately 16 percent of both black and Hispanic residents were impoverished at this time, compared to seven percent of whites and nine percent of Asians (see Figure 9). Figure 9. Poverty Rate by Race, Maryland,

14 e. Access to Care/Health Insurance Coverage The percentage of unknown insurance status within Adventist Behavioral Health Eastern Shore s CBSA is 38.5 percent, according to hospital data. AHRQ s 2010 National Healthcare Disparities Report defines access to healthcare as the efficient and timely use of personal health services to obtain the best health outcomes. The report states that racial and ethnic minority groups, as well as people with low incomes, have disproportionately high rates of uninsurance or coverage through public programs. Overall, minorities tend to have more limited access to healthcare services and the care they do receive is often of poor quality which results in a multitude of healthcare complications (Agency for Healthcare Research and Quality, 2010). In 2010, Hispanics in Maryland were uninsured at more than twice the rate of blacks and more than four times the rate of whites (see Figure 10). Asians are most likely to have health insurance coverage through an employer-based plan than any other racial or ethnic group. Black individuals are more than two times as likely to be covered by Medicaid as whites across the state of Maryland (see Figure 10). According to the U.S. Census Bureau, approximately 12.9 percent of all Maryland residents under the age of 65 were uninsured. Approximately 12.5 percent of Montgomery County residents were uninsured in Across the state, Hispanic males are more likely (37 percent) not to have health insurance coverage than white, non-hispanic men (10 percent) and black, non-hispanic men (17 percent). The trend is similar among females in Maryland: Hispanic women are uninsured at a rate of 30 percent, while almost 8 percent of white, non-hispanic women and 12 percent of black, non-hispanic women are uninsured. White non- Hispanic 8.8% 6.3% 15.9% 62.2% 4.1% Black, non- Hispanic 16.2% 17.3% 10.9% 49.4% 3.7% Hispanic (Any Race) 36.0% 13.1% 4.0% 39.5% 1.5% Asian, non- Hispanic 5.5% 5.9% 8.3% 73.8% 6.3% Uninsured Medicaid Medicare Employment-Based Direct Purchase Figure 10. Health Insurance Coverage of Non-Elderly by Race/Ethnicity, Maryland, (Source: Current Population Survey, Health Insurance Coverage of the Non-Elderly, 2010: 14

15 Within Adventist Behavioral Health Eastern Shore s CBSA, the percentage of Medicaid recipients is 40.6 percent (PCA Informatics-Maryland inpatient discharges, 2011). This high percentage indicates that many of the people that Adventist Behavioral Health Eastern Shore serves are families and individuals with low income and resources. 15

16 Section II. Methodology 16

17 Section II. Methodology a. Establishing Infrastructure and Selecting Priorities Adventist Behavioral Health Eastern Shore is a member of Adventist HealthCare, which formed a Community Benefit Council (CBC) to guide and lead its community benefit activities, including conducting the Community Health Needs Assessment. The Community Benefit Council has representation from various departments within the organization. The Council is being led by Ismael Gama, Associate Vice President of Mission Integration & Pastoral Care Services. As a starting point, the Community Benefit Council decided to research topics in alignment with Montgomery County s Healthy Montgomery Focus Areas of: cancer, cardiovascular diseases, diabetes, maternal & infant health, behavioral health, and obesity. The Community Benefit Council also decided to research additional topics of interest to the hospital including: asthma, influenza, HIV/AIDS, senior health, income and poverty, access to care/health insurance coverage, food access, housing quality, education, and transportation. All of the topics included in this Community Health Needs Assessment were reviewed, discussed and approved by the Adventist HealthCare Community Benefit Advisory Board. Since 2006, we have convened an Advisory Board to help guide our efforts to reduce and eliminate health disparities, to identify community needs, and to help assess and direct our response to those needs. The Advisory Board is comprised of both internal and external (community) leaders. Members include clinicians, researchers, administrators and others from our hospitals, community-based organizations, local and state health departments, University of Maryland, the National Institutes of Health (specifically, the National Institute of Minority Health and Health Disparities), and other public health stakeholder organizations. After completion of the Community Health Needs Assessment, the President s Council at Adventist Behavioral Health will meet to discuss and vote upon initiatives that the hospital will implement to address the needs identified in this report. This active process began in November 2011 with a preliminary meeting of the Community Benefit Advisory Board. 17

18 b. Collecting and Analyzing Data Adventist Behavioral Health Eastern Shore identifies unmet health care needs in our community in a variety of ways. Adventist HealthCare s Center on Health Disparities, which supports Adventist Behavioral Health Eastern Shore, developed and released its 2011 Annual Progress Report, Partnering Toward a Healthier Future: Health Disparities in the Era of Reform Implementation. This progress report offers an update on health disparities affecting communities in Maryland. Much of the information in the first chapter of the report fed into this Community Health Needs Assessment, as it details demographic trends and assesses disparities across a range of issues within three broad health topics affecting our community: maternal and infant health, heart disease and stroke, and cancer. The report incorporates descriptive findings from national, state and county-level databases on the racial and ethnic makeup of the population, the prevalence of disease across these groups, and the rates of receiving appropriate treatment. Information from Adventist HealthCare s Center on Health Disparities 2010 Annual Progress Report, Social Determinants of Health: Promoting Health Equity through Social Initiatives, also helped to inform related sections in the Community Health Needs Assessment. This report summarized the evidence on social factors that influence health disparities among racial/ethnic groups in Maryland, and highlighted efforts to eliminate them. In addition to the research conducted for the annual Center on Health Disparities reports, we also analyzed the U.S. Census Bureau s American Community Survey and Profiles of General Population and Housing Characteristics to produce a broad demographic overview by county, race, and ethnicity. In Maryland, we produced descriptive tabulations based on data from the Maryland Behavioral Risk Factor Surveillance System, the Maryland Cancer Registry, the Maryland Vital Statistics Administration, the Maryland Health Care Commission, and the Maryland Department of Health and Mental Hygiene s (DHMH) Office on Minority Health & Health Disparities, and from DHMH s State Health Improvement Process (SHIP). For the local community of Wicomico County and Dorchester County, we also produced analytic summaries based on data from the Community Dashboard of Peninsula Regional Medical Center, the Maryland Tobacco Resource Center, County Health Rankings and Roadmaps, (DHMH) Environmental Public Health Tracking, Wicomico County Health Department s Local Health Improvement Process and Community Health Needs Assessment, and Dorchester County Health Department s Annual Report. In addition to these data sources, we have also summarized findings from various national and state-level reports on insurance coverage, disease condition, and healthy behaviors released by the Agency for Healthcare Research and Quality, the Kaiser Family Foundation, and the DHMH s Family Health Administration, Office of Chronic Disease Prevention. 18

19 c. Primary Data Collection & Results Community Advisory Board Adventist Behavioral Health Eastern Shore believes that mental health care is best delivered through programs and services that address the needs of the community it serves. The local Community Advisory Board (CAB) of Adventist Behavioral Health Eastern Shore was formed for the purpose of providing better services for our residents and their families, through interactive and participatory input within the group and to treat Shore kids on the Shore. Through regular and productive dialogue with its Community Advisory Board, Adventist Behavioral Health Eastern Shore aims to strengthen its existing programs and address gaps in mental health care. The Community Advisory Board consists of members who have demonstrated an interest in the mental health concerns of the community through their work or volunteer services. This includes, but is not limited to: Parent/Family Navigators, Mid-Shore Mental Health Core Service Agency representative, parents of patients, Dorchester County Department of Juvenile Services Program Supervisor, Wicomico Somerset Regional Core Service Agency representative, Dorchester County Department of Social Services representative, Eastern Shore Mobile Crisis representative, and Dorchester County Public Schools Special Education Non-Public Coordinator. The Community Advisory Board is being led by Kevin Drumheller, Executive Director of Adventist Behavioral Health Eastern Shore, and Barbara Coleman, Scribe. The Community Advisory Board for Adventist Behavioral Health Eastern Shore held its first meeting in November 2012 and meets quarterly. The following are a few topics that were discussed during the meetings gathered from meeting minutes from November 2012 through May 2013: Program/Hospital Updates A description of updates from the hospital and several programs were discussed during the meetings. Some of the program enhancements include: addictions counseling (with in-house and off-site NA groups), music therapy, dance movement therapy, fitness instructor, kickboxing, running group, biking group, and the benefit of Partial Hospitalization Program (PHP) transportation. They have also added latency age Residential Treatment Center services that are individualized per child and implement skills they can use at home (family behavioral change). Expansion opportunities, such as outpatient services, and summary programming were also discussed. Additionally, they discussed an emphasis on Adventist Behavioral Health Eastern Shore using MANDT behavioral intervention, which is a focus on a culture of strong relationship building and not just training. In order to provide a forum to hear direct patient concerns, complaints, problems, and ideas, Adventist Behavioral Health Eastern Shore developed the Residents Council, which is comprised of 2 residents from the boys unit and 2 from the girls unit. The Safety Forum was also developed for the purpose of providing the opportunity for staff from each unity or area to share patient care or safety concerns or comments. The Residents Council and the Safety Forum meet monthly. Additionally, to better meet the needs of female patients, gender-specific groups were added, such as a personal trainer, kickboxing, and scrapbooking. 19

20 Adventist Behavioral Health Eastern Shore currently uses Press Ganey to survey both the patient satisfaction data and patient quality indicators, which include tracking restraints, seclusions, and physical assaults. Results of the quality safety indicators lead to implementation of processes to help Adventist Behavioral Health Eastern Shore meet targets. The following processes have been implemented: o Patient snapshots, listing key issues, preferences, likes, triggers, etc. o Monthly tracers of processes. o MANDT aggression management tool. o MANDT minute at monthly All-Staff meetings (all participate) Initiatives/Trainings Adventist Behavioral Health Eastern Shore (ABH ES) works on different projects and initiatives, and continues to train their staff throughout the year to be knowledgeable and competent to serve its residents and the community. One of the projects that the hospital is working on is the Residential Treatment Center (RTC) Re-tooling Grant. MHA provided $275,000 to RTCs in Maryland to create programs that promote a smoother transition from RTC to the community. With this grant, ABH ES is able to hire additional licensed therapists to allow all youth and families receiving in-home services after discharge to continue with the same therapist who provided care while the child was admitted to the RTC; the hospital is able to partner with the Maryland Coalition of Families to provide their Active Parenting training on the ABH ES campus; and provides a two-day training for all ABH ES therapists and nurses on the ARC model, a trauma model out of the Trauma Center at JRI. In addition, ABH ES provides training on Attachment, Self-Regulation and Competency (ARC) Clinical Services, a framework for intervention with youth and families who have experienced multiple or prolonged traumatic stress. ABH ES is also involved in a LEAN initiative, in which ABH ES Directors receive a 3-day training on the LEAN Process, an efficiency process which empowers staff to problem solve and make decisions. Other ABH ES staff were also trained on key elements of the LEAN Process. Newsletter The Adventist Behavioral Health Eastern Shore newsletter, The Bridge, will be distributed to the Community Advisory Board for review and will be published monthly. Focus areas of the newsletter include resident successes, safety, giving back to the community, building relationships, and a staff-learning tool through the Residents Council Corner. Community Efforts There are several projects and events that Adventist Behavioral Health Eastern Shore is working on with the community and with their partners. The new Mobile Crisis Team in Dorchester County will be available beginning on July 1, In working with Emergency Departments, Eastern Shore Mobile Crisis is being referred as a transitional support piece, and they will have on-site behavioral health assessments 20

21 for Chester River. The Maryland Coalition has proclaimed May as Mental Health Month in the City of Cambridge in Dorchester County. Additionally, ABH ES is involved in the annual Walk/Run and the Torch Relay within the community. 21

22 d. Partnerships Adventist Behavioral Health Easter Shore, a member of Adventist HealthCare, has ongoing partnerships with several community-based organizations on the Eastern Shore of Maryland. Adventist Behavioral Health s Executive Director sits on the Board of Directors for Rural CARES. The goal of Rural CARES on Maryland s Eastern Shore (Caroline, Cecil, Dorchester, Kent, Queen Anne s, Somerset, Talbot, Wicomico and Worcester Counties) is to improve life outcomes for children and youth, ages years, with serious emotional and behavioral challenges who are either (1) in foster care, or (2) at-risk of entering foster care, both at a group home or Residential Treatment Center level of care. The ABH ES Chaplain has also been part of the Rural CARES community and participates in their Cultural and Linguistic Competency Committee. Chaplain Mighty has participated in the Open Table project. This project seeks to assist at-risk persons who want to start a business and do not have the finances or expertise to do so. A committee is formed with individuals who make a reasonable financial contribution, give expertise, supervision and skills and are willing to sit on the committee for at least one year or until the individual can stand on his/her own. In August 2013, Adventist Behavioral Health Eastern Shore was awarded a grant through MHA focusing on providing higher quality of care to at-risk youth placed in Residential Treatment Centers. This grant helped fund a two day trauma training. ABH ES invited all the Eastern Shore Family Navigators to participate in this training at no cost. ABH ES sits on multiple committees through Mid Shore Mental Health Systems. Mid Shore Mental Health Systems (MSMHS) is a Private not-for-profit 501(C)(3) organization, serving Caroline, Dorchester, Kent, Queen Anne s and Talbot Counties. MSMHS was incorporated in 1992 through a collaboration of the five county governments and mental health stakeholders. They are a Core Service Agency (CSA), the Local Mental Health Authority, under contract with the Mental Hygiene Administration (MHA), Department of Health and Mental Hygiene Administration (DHMH). Lastly, Adventist Behavioral Health has convened a Community Advisory Board to help guide our efforts to provide needed services to the Eastern shore. The Community Advisory Board is comprised of external community leaders and family members of children placed in our facility. 22

23 Adventist Behavioral Health Eastern Shore Community Advisory Board Members: Audra Cherbonnier Family Navigator, Parent Maryland Coalition of Families Adelaide (Addie) Eckardt Delegate House of Delegates Rebecca Hutchison Child and Adolescent Coordinator Mid Shore Mental Health Systems Diane Lane Executive Director and Parent Chesapeake Voyagers, Inc. Kenneth Malik Chief Cambridge Police Department Carol Masden Director and Parent Eastern Shore Mobile Crisis Christopher Miele Program Supervisor Department of Juvenile Services Heidi Rochon Director and Parent Maryland Coalition of Families Darlene Sampson Assistant Director of Services Dorchester County Department of Social Services Chalarra Sessoms Child and Adolescent Director Wicomico/Somerset Behavioral Health Authority Bernadett Townsend Family Navigator and Parent Maryland Coalition of Families 23

24 Debbie Usab Director Dorchester County Public Schools Special Education In addition to the advisory board, the staff of Adventist HealthCare and Adventist Behavioral Health participates in various ways in the community. We actively participate in numerous committees, coalitions, and partnerships that provide information on the health needs in the community. The health professionals that provide programs in the community also provide valuable information and knowledge of community needs. e. Other Available Data In addition to data sources previously mentioned, we also utilized data from The Community Needs Index (CNI) ( This online tool identifies the severity of health disparity for every ZIP code in the United States and demonstrates the link between community need, access to care, and preventable hospitalizations (Dignity Health, 2012). For each ZIP code in the United States, The Community Needs Index accounts for the underlying economic and structural barriers that affect overall health, including those related to income, culture/language, education, insurance, and housing. The CNI averages the scores for each barrier condition to produce a final CNI score to represent the socio-economic barriers in each ZIP code. This score can then be used by hospitals to direct community benefit and outreach efforts toward the areas with the greatest need. f. Limitations and Data Gaps Identified Despite extensive efforts to prepare comprehensive sets of health access and health status indicators across races and ethnicities at the county level, the following limitations persist: Much of the data, especially population-adjusted rates across race and ethnicity per county, were not available (e.g. mortality rates by race/ethnicity). Data were not available at the ZIP code level for ZIP codes within Adventist Behavioral Health Eastern Shore s CBSA, i.e., Wicomico County and Dorchester County. There was no Dorchester County data available for several topic areas. Often, databases do not differentiate races in persons of Hispanic origin. Many databases group Asian Americans and Pacific Islanders in an other category. Much of the data were obtained from different sources with various data collection and publication protocols. Some county data collected, processed, and checked could not be used due to privacy concerns related to a small number of observations. Self-reporting in surveys can generate under-reporting or over-reporting, yielding unreliable estimates. No tests were performed to determine the statistical significance of data. 24

25 Section III. Findings 25

26 Part a. Disease Incidence and Prevalence 26

27 Chapter 1. Behavioral Health 27

28 Chapter 1. BEHAVIORAL HEALTH Impact Behavioral health is a state of mental/emotional being and/or choices and actions that affect wellness. 1 Substance abuse and misuse are one set of behavioral health problems. 1 Mental health is a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with challenges. Mental health is essential to personal well-being, family and interpersonal relationships, and the ability to contribute to community or society. 2 Mental disorders are health conditions that are characterized by alterations in thinking, mood, and/or behavior that are associated with distress and/or impaired functioning. Mental disorders contribute to a host of problems that may include disability, pain, or death. 2 Mental illness is the term that refers collectively to all diagnosable mental disorders, such as: depression, anxiety disorders, mood disorders, psychotic disorders, social and emotional issues, alcohol, substance and tobacco use, and suicide (Healthy Montgomery, Behavioral Health Workgroup, 2012). Mental disorders are among the most common causes of disability. The resulting disease burden of mental illness is among the highest of all diseases; mental health disorders are the leading cause of disability in the United States and Canada, accounting for 25 percent of all years of life lost to disability and premature mortality. 2 Mental health also plays a major role in one s ability to maintain good physical health. 2 Good mental health contributes to good physical health and vice versa. 1 Key Takeaways Mental health services are underutilized by minority populations in Maryland. Non-Hispanic whites are twice as likely as minority persons to report having ever seen a provider for a mental health problem, despite equal or greater burden of mental health disorders in minority populations. Maryland high school students had higher than the national average number of suicide attempts requiring medical treatment; a higher percentage of girls than boys had seriously considered attempting suicide. In Maryland, 81 percent of those who committed suicide were men and 19 percent were women; in Wicomico County, the suicide death rate exceeds that of the suicide death rate of Maryland. 1 Substance Abuse and Mental Health Services Administration. (n.d.). Prevention and Behavioral Health. Retrieved July 26, 2013, from SAMHSA: Prevention Training and Technical Assistance: 2 Healthy People (2013, April 10). Mental Health and Mental Disorders. Retrieved July 26,

29 In both Dorchester and Wicomico Counties, the rate of Emergency Department visits related to a behavioral health condition were percent higher and percent higher, respectively, than the state of Maryland s rate. The rate of Emergency Department visits related to domestic violence was percent higher in Dorchester County than the state of Maryland s rate, with black residents having a significantly higher rate than white residents. There is also a higher percentage of reported child maltreatment in Dorchester County compared to Maryland. The drug-induced death rate in Maryland exceeds the national average, and heroin is the primary reason for drug treatment admissions. The prevalence of binge drinking in Wicomico County has increased, with more men reporting binge drinking than women, and more adults aged engaging in binge drinking compared to any other age group. National Data One in four adults, or approximately 57.7 million Americans, experiences a mental health disorder in a given year. One in 17 adults lives with a serious mental illness, such as schizophrenia, major depression or bipolar disorder, and about 1 in 10 children live with a serious mental or emotional disorder. 3 The use of illicit drugs among Americans increased between 2008 and 2010, according to a national survey conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA). The National Survey on Drug Use and Health (NSDUH) showed that 22.6 million Americans age 12 or older (8.9 percent of the population) were current illicit drug users. The rate of use in 2010 was similar to the rate in 2009 (8.7 percent), but remained above the 2008 rate (8 percent) (SAMSHA, 2011). 4 State Data Overview: Approximately 175,000 adults and 62,000 children out of the 5.6 million residents of Maryland live with a mental health illness (National Alliance on Mental Illness, 2010). Seven percent of Maryland residents reported use of illicit drugs in the past month, compared to approximately eight percent nationally (Maryland Drug Control Update, 2010). The drug-induced death rate in Maryland exceeds the national average, with heroin being the primary reason for treatment admissions. 5 3 The National Alliance on Mental Illness (NAMI). Mental Illness: Facts and Numbers SAMHSA. News Release: National survey shows a rise in illicit drug use from 2008 to Maryland Drug Control Update

30 Mental Health: Maryland s Behavioral Risk Factor Surveillance System (BRFSS) data shows an underutilization of mental health services by minority populations. In each of the three major age groups, non-hispanic whites are twice as likely as minority persons to report having ever seen a provider for a mental health problem, despite equal or greater burden of mental health disorders in the minority populations (see Figure 1). Figure 1. Percent Reporting Ever Seeing a Provider for a Mental Health Problem by Race/Ethnicity, Maryland (BRFSS, ) (Left); Percent Reporting 30 Days of Poor Mental Health in Previous Month by Race/Ethnicity, Maryland (BRFSS ) (Right) Maryland adolescents ages are 5 percent below the national average when it comes to exhibiting positive social skills. However, Maryland falls below the national percentage of depressive-like symptoms exhibited among high school students between grades 9-12 (see Figure 2) (DHHS, Office of Adolescent Health, 2011). Figure 2. Positive Social Skills, Depressive Symptoms, and Depressive Episodes among Adolescents ages 12-17, Maryland, (Source: DHHS, Office of Adolescent Health, 2011) 30

31 Among Maryland high school students, 19 percent of females had seriously considered attempting suicide in the previous year compared to 16 percent of males (2011). High school students in Maryland are three percent above the national average for suicide attempts requiring medical treatment (see Figure 3). 6 Figure 3. Suicidal Thoughts, Attempts, and Injuries among High School Students (grades 9-12), Maryland, U.S., Department of Health and Human Services, Office of Adolescent Health. Mental health data for Maryland: Adolescent Health Facts

32 Substance Abuse: Among Maryland residents, 7.29 percent reported using illicit drugs in the past month, compared to the national average of 8.02 percent. Additionally, 3.23 percent of Maryland residents reported using an illicit drug other than marijuana in the past month, which is similar to the national average of 3.58 percent (Maryland Drug Control Update, 2010). Heroin is the most commonly cited drug among primary drug treatment admissions in Maryland, followed by Marijuana (see Figure 4). Figure 4. Substance Abuse Treatment Admissions Data, Maryland, 2010 As a direct consequence of drug use, 807 persons died in Maryland in 2007, which is higher than the number of persons who died in Maryland from either motor vehicle accidents (675) or from firearms (678) in the same year. Maryland drug-induced deaths at 14.4 per 100,000 population exceeded the national rate of 12.7 per 100,000 population (Maryland Drug Control Update, 2010). 32

33 County Data Wicomico County Mental Health: Poor mental health and psychological distress can affect all aspects of a person s life. Recognizing potential mental health issues before they become critical and persistent is very important. In Wicomico County, 79 percent of adults stated that they experienced two or fewer days of poor mental health in the past month in 2011 (Peninsula Regional Medical Center, Community Dashboard, 2013). Although this rate is a slight decrease from 81 percent from 2010, it is still much higher than the 70.9 percent of adults who self-reported good mental health in the state of Maryland. Among the 79 percent of adults in Wicomico County who self-reported good mental health, there was a higher percentage of male residents at 84.5 percent compared to female residents at 73 percent (see Figure 5). Figure 5. Self-Reported Good Mental Health by Gender, Wicomico County, Additionally, non-hispanic whites were more likely to self-report good mental health at 81.8 percent compared to non-hispanic blacks at 73.4 percent (see Figure 6). Figure 6. Self-Reported Good Mental Health by Race/Ethnicity, Wicomico County, Peninsula Regional Medical Center. Creating Healthy Communities Community Dashboard. Wicomico County. (2011). Accessed: 33

34 Social and emotional support refers to feeling loved and cared for by those around us. Individuals who have adequate social and emotional support experience better health outcomes compared to those who lack such support. Research has shown that social and emotional support has beneficial effects on recovery time, coping, and overall longevity. Among Wicomico County adult residents in 2010, 83.4 percent reported they usually or always get the social and emotional support they need. 7 This percent is an increase from 2009 when 70.8 percent of Wicomico County adult residents reported that they usually or always get the social and emotional support they need. 7 In 2012, Wicomico County experienced a rate of 8,050 Emergency Department visits for a behavioral health condition per 100,000 population, which is much higher than the Maryland rate of 5,522 Emergency Department visits per 100,000 population. The Maryland State Health Improvement goal is to reduce the number of Emergency Department visits related to behavioral health conditions to 5,028 visits by 2014 (see Figure 7). Maryland State Health Improvement Process Objective 34 in Wicomico County, 2012 Figure 7. Rate of Emergency Department Visits related to a Behavioral Health Condition, Wicomico County, MD, Suicide: From , the age-adjusted death rate due to suicide in Wicomico County was 9.5 deaths per 100,000 population, which was down from 10.9 deaths per 100,000 population from (see Figure 8). Although the suicide death rate of 9.5 deaths per 100,000 population meets the Healthy People 2020 target, it falls slightly short of meeting the Maryland State Health Improvement Process 2014 target of 9.1 suicide deaths per 100,000 population. 8 Wicomico County s death rate due to suicide is also still higher than the rate of the state of Maryland at 8.9 deaths per 100,000 population. 8 8 Maryland Department of Health and Mental Hygiene. Maryland State Health Improvement Process (SHIP). Wicomico County. (2012). Accessed: 34

35 Age-Adjusted Death Rate due to Suicide, Time Series Data, Wicomico County, Figure 8. Age-Adjusted Death Rate due to Suicide, Wicomico County, Domestic Violence: The rate of Emergency Department visits related to domestic violence/abuse per 100,000 population in Wicomico County is at a relatively low 71.6 compared to the state of Maryland s rate of (see Figure 9). This rate is already well below the Maryland State Health Improvement Process 2014 target of Emergency Department visits related to domestic violence/abuse per 100,000 population. Maryland State Health Improvement Process Objective 12 in Wicomico County, 2012 Figure 9. Rate of ED visits related to Domestic Violence in Wicomico County, MD, Child Abuse/Maltreatment: In Wicomico County in 2012, the rate of non-fatal child maltreatment cases reported to social services was 4.2 per 1,000 children under age 18, which is a slight increase from the 2011 rate of 3.7 per 1,000 children (see Figure 10). However, Wicomico County s rate (4.2 cases per 1,000 children) is still lower than the state of Maryland s rate of 5.3 per 1,000 children, and meets the Maryland s State Health Improvement Process 2014 target of 4.8 cases per 1,000 children (see Figure 10). Maryland State Health Improvement Process Objective 7 in Wicomico County, 2012 Figure 10. Rate of Indicated Non-fatal Child Maltreatment Cases in Wicomico County, MD,

36 Substance Abuse Alcohol: Among Wicomico County residents, 14.2 percent reported binge drinking at least once during 30 days (prior to taking the survey that was used to gather this statistical data), which was similar to the overall prevalence of reported binge drinking in Maryland (14.6 percent) (BRFSS, 2010). The prevalence of binge drinking increased in Wicomico County from 9.5 percent in 2009 to 14.2 percent in 2011 (see Figure 11). In addition, Wicomico County s 14.2 percent meets the Healthy People 2020 target of reducing the proportion of adults aged 18 years and older engaging in binge drinking during the past 30 days to 24.3 percent. 8 Adults who Binge Drink in Wicomico County, Figure 11. Adults who Bing Drink in Wicomico County, Time Series Data, More men reported binge drinking (20.4 percent) than women (7.2 percent), and adults ages (21.8 percent) were more likely than any adults in any other age group to report engaging in binge drinking (see Figures 12 and 13). Figure 12. Adults who Bing Drink by Gender, Figure 13. Adults who Bing Drink by Age, Wicomico County, Wicomico County,

37 Drug-Induced Mortality Rate: In 2012, the rate of drug-induced deaths in Wicomico County was 13.8 per 100,000 population, which was somewhat higher than Maryland s rate of 12.6 per 100,000 population (Maryland SHIP, 2012). By 2014, the Maryland State Health Improvement Process target is to reduce drug induced deaths to 11.3 per 100,000 population (see Figure 14). Maryland State Health Improvement Process Objective 29, Wicomico County, 2012 Figure 14. Rate of Drug-Induced Deaths in Wicomico County, MD, Dorchester County Mental Health: According to the Maryland State Health Improvement Process, there were 10,885 Emergency Department visits related to a behavioral health condition per 100,000 population in Dorchester County in This is an increase of 66 Emergency Department visits from 2011 and it is double the Emergency Department visits in the state of Maryland (5,522) in 2012 (see Figure 15). There is a huge disparity among racial and ethnic groups in the rate of Emergency Department visits for a behavioral health condition. Non-Hispanic black residents of Dorchester County experienced the highest rate of Emergency Department visits related to behavioral health conditions at 15,138, compared to 3,737 visits among Hispanics and 9,789 visits among whites, per 100,000 population (see Figure 15). Maryland State Health Improvement Process Objective 34, Dorchester County, 2012 Figure 15. Rate of Emergency Department Visits Related to a Behavioral Health Condition, Dorchester County, MD, Maryland Department of Health and Mental Hygiene. Maryland State Health Improvement Process (SHIP). Dorchester County. (2012). Accessed: 37

38 Domestic Violence: There were Emergency Department visits related to domestic violence/abuse per 100,000 population in Dorchester County in 2012, which is far higher than the Maryland rate of Emergency Department visits. Non-Hispanic blacks were more likely than other racial/ethnic groups to visit the Emergency Department due to domestic violence/abuse. The Maryland State Health Improvement Process aims to reduce Emergency Department visits related to domestic violence to per 100,000 population by 2014 (see Figure 16). Maryland State Health Improvement Process Objective 12, Dorchester County, 2012 Figure 16. Rate of ED Visits Related to Domestic Violence, Dorchester County, MD, Child Abuse/Maltreatment: Dorchester County s rates of child abuse/maltreatment are poor compared to the state baseline. Dorchester County had 9.5 per 1,000 children (under age 18) cases of indicated non-fatal child maltreatment reported to social services, while the state of Maryland had 5.3 cases per 1,000 children (see Figure 17). The Maryland State Health Improvement Process target is to reduce the rate of child maltreatment to 4.8 cases per 1,000 by Maryland State Health Improvement Process Objective 7, Dorchester County, 2012 Figure 17. Maryland State Health Improvement Process to Reduce Child Maltreatment, Dorchester County, Substance Abuse According to Environmental Public Health Tracking, Dorchester County had 3 alcoholinduced deaths among the total population in 2008, and 12.2 percent of the population were binge drinkers. This percentage of binge drinkers is relatively low compared to Maryland s 13.8 percent of binge drinkers in Department of Health and Mental Hygiene. EPHT County Profiles. Dorchester County. ( ) Accessed: 38

39 Spotlight on Smoking & Tobacco Use Impact Tobacco use is the single most preventable cause of death and disease in the United States. Smoking kills more people than alcohol, AIDS, car crashes, illegal drugs, murders, and suicides combined and thousands more die from other tobacco-related causes such as fires caused by smoking (more than 1,000 deaths/year nationwide) and smokeless tobacco use (Campaign for Tobacco Free Kids, The Toll of Tobacco in Maryland, 2013). National Data An estimated 46 million American adults currently smoke cigarettes, and cigarette smoking causes approximately 443,000 deaths annually (CDC, 2010). Tobacco costs the U.S. more than $96 billion in health care expenditures and $97 billion in lost productivity each year. While the United States has made major progress against tobacco use, one in five Americans still smokes, and about 4,000 kids try their first cigarette each day. In the U.S. in 2011, the high school smoking rate was 18.1 percent, and the adult smoking rate was 19.0 percent (Campaign for Tobacco Free Kids, The Toll of Tobacco in Maryland, 2013). State Data In Maryland, 14.9 percent of the adult population (aged 18+ years), over 640,000 individuals, are current cigarette smokers (see Figure 18) (BRFSS, ). Across all states, the prevalence of cigarette smoking among adults ranges from 9.3 percent to 26.5 percent; Maryland ranks 4th among the states (BRFSS, ). Figure 18. Current Smoking among Adults by Demographic Characteristics (Source: BRFSS, ) 39

40 Among youth aged years, 8.8 percent smoke in Maryland. The range across all states is 6.5 percent to 15.9 percent; Maryland ranks 6th among the states (BRFSS, ). Among adults aged 35+ years, over 6,900 died as a result of tobacco use per year, on average, during This represents a smoking-attributable mortality rate of 261.9/100,000. Maryland's smoking-attributable mortality rate ranks 23rd among the states (CDC, Tobacco Control State Highlights 2010 Maryland). County Data Wicomico County In 2011, 21.3 percent of adults smoked cigarettes in Wicomico County (see Figure 19). Although the percentage of adults who smoke cigarettes has decreased over time, it has not met the Maryland SHIP 2014 target of 14.4 percent, or the Healthy People 2020 target of 12.0 percent. Adults who Smoke in Wicomico County, Figure 19. Adults aged 18 years and older who Smoke Cigarettes Time Series Data, Wicomico County, Of the adults who smoke, non-hispanic black residents of Wicomico County were 27.6 percent more likely than non-hispanic white residents to smoke cigarettes (see Figure 20). Male residents of Wicomico County were also 4 percent more likely than female residents to smoke cigarettes (see Figure 21). 40

41 Figure 20. Adults who Bing Drink by Gender, Figure 21. Adults who Bing Drink by Age, Wicomico County, Wicomico County, Adolescents who Smoke In 2010, 21.6 percent of Wicomico County adolescents in grades 9 through 12 had smoked cigarettes at least once during the last 30 days (prior to taking the survey that was used to gather this statistical data). This rate was an increase from 2008 when only 17.8 percent of teens smoked cigarettes, and is higher than the Healthy People 2020 target of 16 percent (see Figure 22). Teens who Smoke in Wicomico County, Figure 22. Teens who Smoke in Wicomico County,

42 Dorchester County In Dorchester County, 19.7 percent of adults smoke, which is a high compared to the 14.9 percent of adults who smoke in the state of Maryland (DHMH, EPHT County Profiles, ). Over the course of 10 years, the use of cigarettes by Dorchester County middle and high school youth has decreased. There is a significant change in use from 2000 when 20 percent of Dorchester County adolescents used cigarettes to 2010 when 13.4 percent used cigarettes (see Figure 23). It is interesting to note, however, that use of cigars did not decrease during that same timeframe. Furthermore, the percent of youth using tobacco products in Dorchester County is still higher than in the state of Maryland overall. In 2010, 9.6 percent of Maryland middle and high school youth used cigarettes and 9.5 percent used cigars. 11 Figure 23. Current Use of Tobacco Products by Dorchester County Middle & High School Youth, MDQuit: Maryland s Tobacco Resource Center. Dorchester County Fact Sheet. (2012). Accessed: 42

43 Local Resources Behavioral Health In the Adventist Behavioral Health Eastern Shore service area there are behavioral health services available in both counties. Three hospitals provide acute care in-patient services, including: Adventist Behavioral Health, Shore Health System, and Peninsula Regional Medical Center (PRMC). Shore Behavioral Health Hospital is part of the Shore Health System. Outpatient services are offered by Shore Health and PRMC. Adventist Behavioral Health s Residential Treatment Center provides 24-hour care through psychiatric treatment for individuals between the ages of years old with mental illness or emotional/behavioral problems. Mid-Shore Mental Health System (MSMHS) is a not-for-profit collaboration providing a continuum of services (individual counseling, outpatient services, and support). MSMHS provides information, resources and advocacy support. A 24-hour crisis hotline is available through the Eastern Shore Operations Center. Private practitioners provide individual and group counseling services. Addiction and substance abuse programs are provided by the Delmarva Family Resources and the County Health Departments. Additionally, Mid Shore Fresh Start provides transitional supportive housing. The Wicomico County Health Department offers a range of behavioral health services including: The Minority Youth Outreach Program, Outpatient Mental Health Program, Psychiatric Rehabilitation Program, and Targeted Case Management. 43

44 Chapter 2. Cancer 2.1 Breast Cancer 2.2 Lung Cancer 2.3 Colorectal Cancer 2.4 Prostate Cancer 2.5 Cervical Cancer 2.6 Skin Cancer 2.7 Oral Cancer 2.8 Thyroid Cancer 44

45 Chapter 2. CANCER OVERVIEW Impact Cancer is a term used for diseases in which abnormal cells divide without control and are able to invade other tissues. Cancerous cells are also called malignant cells. If the spread is not controlled, it can result in death. There are many different kinds of cancer. Cancer can develop in almost any organ or tissue, such as the lung and/or bronchus, colon, breast, skin, bones, or nerve tissue. There are many causes of cancer, including benzene and other chemicals, drinking excess alcohol, environmental toxins, excessive sunlight exposure, genetic problems, obesity, radiation, viruses, and other unknown causes (NIH, NCBI, 2013). Key Takeaways Overall, cancer incidence rates are declining in Maryland. Despite clearly poor health outcomes among certain racial and ethnic groups in particular regions of the state, great strides have been made in the African American community over the years. Both cancer incidence and mortality rates for this group have declined more significantly than among white residents, suggesting that efforts to educate residents about the importance of screening and regular medical care following a cancer diagnosis have been effective. In Wicomico County, overall cancer mortality rates are among the highest of all counties in Maryland. Prostate and breast cancer incidence rates are higher in Wicomico and Dorchester Counties than both the state and national rates. In addition, Wicomico county residents have a higher incidence and mortality rate of lung and bronchus cancer than the state rate, and white residents have a higher mortality rate from lung and bronchus cancer than black residents. National Data In recent years, cancer has been the second highest cause of death in the United States, with only heart disease surpassing it. In 2012, about 577,190 Americans are expected to die of cancer, which is more than 1,500 people a day. 1 The three most common cancers in men in the United States are prostate cancer, lung cancer, and colon cancer; in women in the United States, the three most common cancers are breast cancer, colon cancer, and lung cancer (NIH, NCBI, 2013). 1 National Cancer Institute at the National Institutes of Health. Accessed American Cancer Society. Cancer Facts and Figures

46 State Data Though the overall cancer incidence rate in Maryland is steadily declining at a pace comparable to the national rate, a deeper look at specific populations and counties indicates that disparities exist, especially concerning the rate of mortality (see Figure 1) (Maryland DHMH, Cancer Report, 2010). Figure 1. Cancer Mortality Rates, by Race, Maryland, and U.S., 2010 (Sources: Healthy People 2020, National Vital Statistics System; and Maryland DHMH Vital Statistics Administration) For many years, the African American community has experienced especially elevated cancer rates compared with other racial and ethnic groups. However, in recent years the incidence and mortality rates for this community have declined even more significantly than among the white population for several forms of cancer, suggesting the effectiveness of programs, events and other efforts to increase awareness about preventative measures and the importance of regular medical care and screenings. 46

47 County Data Overall cancer mortality rates for Wicomico County are among the highest in the state of Maryland. Comparison data between and shows a slight decrease in mortality rates. The overall cancer mortality rates for both Dorchester County and Wicomico County are above the Maryland 2014 target. Comparison data between and also show a slight decrease in mortality rates in Dorchester County (see Figure 2). Figure 2. Cancer Mortality Rates per 100,000 Population, County Comparison, Maryland, (Source: Maryland DHMH Vital Statistics Administration) 47

48 Wicomico and Dorchester Counties both had higher mortality rates for lung and bronchus cancer and colorectal cancer compared to Maryland overall and the U.S. (see Figure 3). Cancer Mortality Rates per 100,000 in U.S., MD, Wicomico & Dorchester County, 2010 Figure 3. Cancer Mortality Rates per 100,000 Population, U.S., Maryland, Wicomico County and Dorchester County, Wicomico County s incidence rates of prostate cancer and lung and bronchus cancer exceeded both the state and national rates (see Figure 4). Cancer Incidence Rates per 100,000 in U.S., MD, Wicomico & Dorchester County, 2010 Figure 4. Cancer Incidence Rates per 100,000 Population, U.S., Maryland, Wicomico County and Dorchester County National Cancer Institute. Accessed: 48

49 Chapter 2.1 BREAST CANCER Impact According to the American Cancer Society, breast cancer is the second leading cause of cancer death and the second most common type of cancer among women in the U.S. The greatest risk factor in developing breast cancer is age. Since 1990, breast cancer death rates have declined progressively due to advancements in treatment and detection. National Data In the United States, 210,203 women were diagnosed with breast cancer in 2008, and 40,589 women died from the disease (CDC, U.S. Cancer Statistics). The Healthy People 2020 national health target is to reduce the breast cancer death rate to 20.6 deaths per 100,000 females. State Data Aside from non-melanoma skin cancer, breast cancer is the most common cancer among women in the United States. Maryland has the 6 th highest breast cancer mortality rate in the United States, also making it the second leading cause of cancer deaths among women, behind lung cancer (Maryland DHMH, Cancer Report, 2010). Though incidence and mortality rates have declined since 2003, the percentage of women in Maryland over 50 who report having a mammogram in the past two years (about 78 percent) lags behind the national average of about 82 percent. The narrowing gap in incidence and mortality rates between white and black women is likely a result of the fact that black women over the age of 50 in Maryland report having had mammograms more frequently than white women (see Figure 5). Figure 5. Women Age 50+ Reporting Having Had Mammogram in Last 2 Years by Race,

50 Despite marginal improvements in incidence rates from (see Figure 6), black women across the state died from breast cancer at much higher rates than white women in 2007 (see Figure 7). Figure 6. Breast Cancer Incidence Rate by Race, Maryland Figure 7. Breast Cancer Mortality Rate by Race, Maryland, County Data From the incidence of breast cancer in Dorchester County was per 100,000 population, which is higher than the rate of per 100,000 population in Wicomico County, or per 100,000 population in Maryland overall. During the same time period, the death rate due to breast cancer was lower in Dorchester County (17.6 per 100,000 population) than the rates in Wicomico County (24.0 per 100,000 population) or the state (24.5 per 100,000 population). 3 3 National Cancer Institute. (2013). Accessed: 50

51 Chapter 2.2 LUNG CANCER Impact Lung cancer forms in the tissues of the lung, usually in the cells lining air passages. More people die from lung cancer than any other type of cancer. National Data It is estimated that over 160,000 individuals died from lung cancer in (National Cancer Institute). Lung cancer is the second most common cancer for all males in the U.S., as well as for white and American Indian/Alaska Native females, and is the third most common cancer among black, Asian/Pacific Islander, and Hispanic females (Healthy Montgomery, 2012). State Data Lung cancer is the leading cause of cancer-related death for both men and women in Maryland. However, the incidence and mortality rates of lung cancer have decreased in Maryland, with the incidence rate among blacks declining more rapidly than among whites (21 percent decline and 7 percent decline, respectively) (Maryland DHMH, Cancer Report, 2010). Blacks in Maryland now have a lower incidence rate of lung cancer than do whites and both groups have nearly equal mortality rates. County Data In Wicomico County, the incidence rate of lung and bronchus cancer is higher among whites than blacks (see Figure 8). Furthermore, white residents of Wicomico County die from lung and bronchus cancer more frequently than black residents (see Figure 9). Compared to the state of Maryland s lung and bronchus cancer incidence and death rate, Wicomico County s rate is significantly higher (see Figure 8). 51

52 Lung Cancer Incidence Rate per 100,000 in U.S., Maryland and Wicomico County, 2010 U.S Maryland Hispanic Asian Black White Wicomico Incidence Rate Figure 8. Lung Cancer Incidence Rate per 100,000 population in United Sates, Maryland and Wicomico County, Lung Cancer Mortality Rate per 100,000 in U.S., Maryland and Wicomico County, 2010 Figure 9. Lung Cancer Mortality Rate per 100,000 population in U.S., Maryland and Wicomico County, In Dorchester county black residents have the highest incidence rates of lung cancer. 4 ** Note: For a Spotlight on Smoking & Tobacco Use, see Chapter 1 Behavioral Health** 4 Community Commons. Community Health Needs Assessment. (2013). Accessed: 52

53 Chapter 2.3 COLORECTAL CANCER Impact Colorectal cancer, cancer of the colon or rectum, is the second leading cause of cancer-related deaths in the United States. The Centers for Disease Control and Prevention estimates that if all adults aged 50 or older had regular screening tests for colon cancer, as many as 60 percent of the deaths from colorectal cancer could be prevented (NCI, 2012). National Data In the United States in 2009, over 130,000 people were diagnosed with colorectal cancer and over 51,000 people died from the disease (National Cancer Institute). State Data Incidence and mortality rates for colorectal cancer declined in Maryland between 2003 and 2007, with incidence among black individuals decreasing more significantly than whites (see Figures 12 and 13). This is likely due to the fact that Maryland surpasses the Healthy People 2010 target for colorectal cancer screening; at least 70 percent of adults of all races over the age of 50 underwent a sigmoidoscopy or colonoscopy in 2008 (Maryland DHMH, Cancer Survey, 2008). Colorectal cancer is largely preventable with screening tests, which find precancerous growths early enough to either cure the disease or prevent further cancerous growth with surgery. White Black Incidence Rate Source: Maryland Cancer Report, Rates are per 100,000 and are age-adjusted to 2000 U.S. standard population. Figure 12. Colorectal Cancer Incidence Rate per 100,000 Population by Race, Maryland,

54 White Black Mortality Rate Source: Maryland Cancer Report, Rates are per 100,000 and are age-adjusted to 2000 U.S. standard population. Figure 13. Colorectal Cancer Mortality Rate per 100,000 Population by Race, Maryland, County Data Although the screening rates and incidence rates of colorectal cancer among all races in Wicomico and Dorchester Counties are relatively similar, mortality rates were still much higher for blacks than whites or other races in 2007, indicating that blacks may be getting systematically less or inferior follow-up care post-screening (see Figure 14). Colorectal Cancer Mortality Rates per 100,000 by Race in Maryland, Wicomico County and Dorchester County, 2007 Mortality Rate per 100,000 Population All Maryland Wicomico County Dorchester County White Black Other Figure 14. Colorectal Cancer Mortality Rates per 100,000 by Race, Wicomico County, Dorchester County, and Maryland, Network of Care. Wicomico County Local Health Improvement Process. (2013). Accessed: 54

55 Chapter 2.4 PROSTATE CANCER Impact Prostate cancer is the most common form of cancer among men in the United States. It is second only to lung cancer as a cause of cancer-related death among men. The prostate is a gland in the male reproductive system found below the bladder and in front of the rectum. Prostate cancer forms in tissues of the prostate and usually occurs in older men. National Data It is estimated that 241,740 men were diagnosed with prostate cancer and that 28,170 men died of the disease in the United States in 2012 (National Cancer Institute). State Data Maryland is ranked 11 th in the country for prostate cancer mortality, and similar to the national data, prostate cancer is also the second leading cause of cancer deaths among men in Maryland, behind lung cancer. Incidence and mortality rates have been declining, but blacks are still diagnosed with and die from prostate cancer nearly 30 percent more often than whites (Maryland DHMH, Cancer Report, 2010). The racial disparities seen in prostate cancer incidence and mortality rates across the state are not surprising, given the fact that black men and men of other races are screened for the disease less frequently than are white men. For example, in 2007, 49 percent of black men age 45 and older in Maryland indicated that they had undergone a prostatespecific antigen (PSA) test in the last year, while just over 60 percent of white men had the test (Maryland DHMH, Cancer Report, 2010). County Data Wicomico County had an annual prostate cancer incidence rate of per 100,000 population, while Dorchester County annual prostate cancer incidence rate is per 100,000 population. Compared to the state of Maryland, Wicomico County had a higher incidence rate (by 26) and Dorchester had a lower incidence rate (by 25) of prostate cancer. 4 From , the prostate cancer mortality rate in Wicomico County was 30.2 per 100,000 population, and in Dorchester County it was 20.7 per 100,000 population. The prostate cancer mortality rate in Wicomico County is higher (by 5.2) than the state of Maryland rate, while the rate in Dorchester County is 4.3 lower than the state rate. 3 55

56 Chapter 2.5 CERVICAL CANCER Impact One out of every 145 women in the United States will be diagnosed with cervical cancer in their lifetime. Early cervical cancer can be cured by removing or destroying the pre-cancerous or cancerous tissue. Human papillomavirus (HPV), which is transmitted through sexual contact, has been identified as the main cause of cervical cancer. National Data It is estimated that 12,170 women were diagnosed with cervical (uterine cervix) cancer and that 4,220 women died of the disease in the United States in 2012 (National Cancer Institute). State Data Between 2003 and 2007, cervical cancer incidence rates decreased among Maryland women, bringing the state s overall incidence rate (6.4 percent) lower than the national average (7.8 percent), with black women having a higher incidence rate of cervical cancer than white women (see Figure 15) White Women Black Women Incidence Rate Source: Maryland Cancer Report, Rates are age-adjusted to 2000 U.S. standard population. Figure 15. Cervical Cancer Incidence Rate by Race, Maryland

57 However, mortality rates for cervical cancer increased during this time period, particularly for black women (see Figure 16). White Women Black Women Mortality Rate Source: Maryland Cancer Report, Rates are age-adjusted to 2000 U.S. standard population. Figure 16. Cervical Cancer Mortality Rate by Race, Maryland, This inverse relationship between incidence and mortality is further complicated by the rate at which Maryland women are screened for cervical cancer: in 2010, the vast majority of both white and black women over the age of 18 had a pap test in the last three years, at rates higher than or in-line with the Healthy People 2010 target (see Figure 17). Figure 17. Women 18+ Reporting Having Had Pap test in Last 3 Years by Race/Ethnicity, 2010 These combined data points may suggest that women especially black women receive poor care following diagnosis of cervical cancer. In fact, studies have shown that despite abundant healthcare resources in the United States, women who belong to minority groups or are socioeconomically disadvantaged have not equally benefited from Pap test screening. This is usually due to the presence of comorbid diseases and failure to have follow-up visits for colposcopic evaluation. 6 6 Garner, E. (2003). Cervical Cancer: Disparities in Screening, Treatment, and Survival. Cancer Epidemiology, Biomarkers & Prevention. 12: 242s-247s. 57

58 County Data The incidence rate of cervical cancer in Wicomico County, at 9.5 cases per 100,000 female residents, was higher than both the state of Maryland incidence rate (7.1 per 100,000 population) and the national rate (8.1 per 100,000) from (NCI, State Cancer Profiles, 2013). Cervical Cancer Incidence Rate per 100,000 in U.S., Maryland and Wicomico County, Figure 18. Cervical Cancer Incidence Rate per 100,000 population in U.S., Maryland, Wicomico County,

59 According to Wicomico County Health Department s Local Health Improvement Process, nearly 88 percent of women in Wicomico County had a Pap test in 2010, which is an increase since 2004 (see Figure 19). Pap Test History Time Series Data, Wicomico County, Percent Figure 19. Pap Test History, Time Series Data, Wicomico County, (Source: Wicomico County Health Department, Local Health Improvement Process, Accessed 2013: 59

60 Chapter 2.6 SKIN CANCER Impact Skin cancer is the uncontrolled growth of abnormal skin cells. It occurs when unrepaired DNA damage to skin cells (most often caused by ultraviolet radiation from sunshine or tanning beds) triggers mutations, or genetic defects, that lead the skin cells to multiply rapidly and form malignant tumors. One in five Americans will develop skin cancer in the course of a lifetime (Skin Cancer Foundation, 2013). National Data Skin cancer is the most common type of cancer in the United States. Each year, more than 68,000 Americans are diagnosed with melanoma, and another 48,000 are diagnosed with an early form of the disease that involves only the top layer of skin. Also, more than 2 million people are treated for basal cell (more common) or squamous cell skin cancer each year. It is estimated that there were less than 1,000 deaths from skin cancer in the U.S. in 2012 (National Cancer Institute). State Data Melanoma of the skin is the most dangerous type of skin cancer, and is the only type of skin cancer reportable in Maryland Cancer Registries. Melanoma incidence rates have been on the rise in Maryland, increasing from 19.4 per 100,000 population in 2003 to 21.2 per 100,000 population in 2007 (Maryland DHMH, Cancer Report, 2010). County Data From , the annual age-adjusted incidence rate for melanoma of the skin was 36.8 per 100,000 population in Wicomico County, and 25.8 per 100,000 population in Dorchester County. Incidence rates for both counties were higher than the state of Maryland and U.S. rates (21.2 per 100,000 population and 19.0 per 100,000 population, respectively) (National Cancer Institute, 2013). White residents in both counties have higher skin cancer incidence rates than other racial groups. From , the white population (including Hispanics) in Wicomico County had a skin cancer incidence rate of 44.8 per 100,000 population, while white residents of Dorchester County had an incidence rate of 32.3 per 100,000 population (Community Commons, CHNA, 2013). The incidence rate in both counties is higher than the incidence rate of skin cancer in the state of Maryland for the white population (including Hispanics). White men (including Hispanics) show the greatest disparity in incidence rates compared to County averages. From , the skin cancer incidence rate for white men (including Hispanics) in Wicomico County was 49.7 per 100,000 population, while Dorchester County s incidence rate for this group was 57.5 per 100,000 population, and the incidence rate in the state of Maryland was 36.7 per 100,000 white men (Community Commons, CHNA, 2013). 60

61 Chapter 2.7 ORAL CANCER Impact Oral cancer is cancer that forms in the tissues of the oral cavity (the mouth and lips) or the oropharynx (the part of the throat at the back of the mouth). Each year in the United States, more than 21,000 men and 9,000 women are diagnosed with oral cancer, and most of them are over 60 years old (National Cancer Institute, 2013). Using tobacco and drinking are risk factors for oral cancer, and three out of four people with oral cancer have used tobacco, alcohol, or both (National Cancer Institute, 2013). National Data It is estimated that 40,250 men and women (28,540 men and 11,710 women) were diagnosed with cancer of the oral cavity and oropharynx and that 7,850 men and women will die of the disease in the United States in 2012 (National Cancer Institute). State Data In 2007, Maryland ranked 23 rd highest for mortality caused by oral cancer (Maryland.gov). There were 2,784 cases and 148 deaths caused by oral cancer. From deaths due to oral cancer decreased by 2.6 percent each year (CDC). However, incidence rates between have been rising by 2.9 percent each year. When current smokers have participated in smoking cessation programs for 3-5 years, it has been found that oral cancer risk is reduced by 50 percent (Maryland.gov). Screening for oral cancer is as important as participating in cessation programs. In 2008, 40 percent of Marylanders 40 years and older received oral cancer screenings that lead to early detection and treatment. Figure 20 shows the stage at diagnosis for oral cancer in Maryland from 2003 through Figure 20. Oral Cancer by Stage at Diagnosis (Source: Maryland Cancer Registry, 2011) 61

62 County Data From , the age-adjusted incidence rate for oral cancer in Wicomico County was 9.2 per 100,000 population, while Dorchester County s oral cancer incidence rate was 10 per 100,000 population (see Figure 21). Compared to Maryland overall, Wicomico County had a slightly lower incidence rate of oral cancer, while Dorchester County had a slightly higher incidence rate of oral cancer. Oral Cancer Incidence Rate per 100,000 in U.S., Maryland, Wicomico & Dorchester County, Figure 21. Oral Cancer Incidence Rate per 100,000 Population in United States, Maryland, Wicomico County, Dorchester County, (Source: Wicomico County Health Department, Local Health Improvement Process, Accessed 2013: 62

63 Chapter 2.8 THYROID CANCER Impact Thyroid cancer forms in the thyroid gland, an organ at the base of the throat that makes hormones that help control heart rate, blood pressure, body temperature, and weight. Four main types of thyroid cancer are papillary, follicular, medullary, and anaplastic thyroid cancer, based on how the cancer cells look under a microscope. Normal thyroid cells grow and divide to form new cells as the body needs them, but if the process goes wrong and new cells form when the body does not need them, then the buildup of extra cells forms a mass of tissue (a nodule, or tumor), which may either be benign (not cancer) or malignant (cancer). National Data It is estimated that 56,460 men and women (13,250 men and 43,210 women) were diagnosed with cancer of the thyroid and that 1,780 men and women died of the disease in the United States in 2012 (National Cancer Institute). On the national level, 18.3 per 100,000 white females and 17.7 per 100,000 Asian/Pacific Islander females reported having thyroid cancer from (SEER, 2012). However, mortality rates remained constant among the different genders and races. Maryland incidence and mortality rates are about even with national rates at 12.1 percent and 0.5 percent, respectively. Incidence and mortality rates for thyroid cancer in Maryland have improved over the last several years (NCI, State Cancer Profiles, 2012). From , the annual thyroid cancer incidence rate for Maryland averaged 710 people per year, and the annual death rate was 0.5 per 100,000 population, with an average of 27 deaths per year (NCI, State Cancer Profiles, 2012). 63

64 Figure 22. Thyroid Cancer Incidence Rates, , Maryland (NCI, State Cancer Profiles, accessed 2013) County Data As illustrated in Figure 22, Wicomico County has one of the lowest incidence rates of thyroid cancer in the state of Maryland. Wicomico County had a thyroid incidence rate of with 8.4 per 100,000 people from (NCI, State Cancer Profiles, 2013). There was no data available on thyroid cancer in Dorchester County. 64

65 Local Resources Cancer Cancer resources and services in Adventist Behavioral Health Eastern Shore s Community Benefit Service Area are provided in various settings, including county health departments, local hospitals, and clinics. The following providers offer services in the form of cancer prevention, diagnosis, treatment, and support: Wicomico County Health Department offers several cancer programs and initiatives including but not limited to: the Breast and Cervical Cancer Program, which provides low-income, uninsured, and underinsured women screening services including clinical breast exams, mammograms, pap tests, and diagnostic services; Closing the Gap: Hispanic Women and Breast Cancer Program, which provides case management services to find, refer, and register underinsured and uninsured Hispanic women into a breast cancer screening program. The Cancer and Tobacco Coalition provide underserved populations in Wicomico County with access to tobacco and cancer control resources within the Cancer and Tobacco Coalition Directory. Dorchester County Health Department provides services for breast, cervical, and colorectal cancer including: Breast and Cervical Cancer Services, which provides examinations, screenings, diagnosis, and treatment at the Health Department or in the private sector to low-income, uninsured or underinsured women aged 40 years or above. The Colorectal Cancer Screening Program offers free colorectal cancer examinations and screenings for qualified residents over the age of 50 years old that are uninsured, underinsured, or have a family history of colon cancer or adenomatous polyps. Patients must also satisfy financial requirements for eligibility. University of Maryland Shore Regional Health System offers a full-range of services through the Shore Regional Cancer Center and Requard Center for Radiation Oncology. Outpatient services are provided at both Memorial Hospital and Dorchester General Hospital. The Breast Center at Memorial Hospital provides diagnostic services, genetic testing, counseling, and treatment. The Wellness for Women program offers breast examinations and screenings at monthly clinics for uninsured or underinsured women that satisfy income requirements. Peninsula Regional Medical Center provides cancer services through the Richard A. Henson Cancer Institute, which offers services including nutrition therapy, exercise programs, the Patient Navigator program, and the Palliative Care program. The American Cancer Society works with Peninsula Regional Medical Center and Shore Regional Cancer Center to provide supportive services through the Look Good, Feel Better program for women going through breast cancer treatment. 65

66 Chapter 3. Heart Disease and Stroke 66

67 Chapter 3. HEART DISEASE and STROKE HEART DISEASE Impact Heart disease and stroke are among the most widespread and costly health problems facing our nation today, even though they are also among the most preventable. Heart disease and stroke are leading causes of death for both women and men. Coronary heart disease, often simply called heart disease, is the main form of heart disease. It is a disorder of the blood vessels of the heart that can lead to heart attack. A heart attack occurs when an artery becomes blocked, preventing oxygen and nutrients from getting to the heart. Heart disease is one of several cardiovascular diseases, which are diseases of the heart and blood vessel system. Other cardiovascular diseases include stroke, high blood pressure, angina (chest pain), and rheumatic heart disease (National Heart Lung and Blood Institute, 2012). Key Takeaways Similar to data in national statistics, heart disease and stroke affect Maryland s white population more frequently than its black population. Although incidence rates have declined among all racial and ethnic groups in the state over the last several years, blacks and seniors experience high death rates for diseases of the heart. Similarly, minority populations experience more of the negative effects of stroke: differences in stroke incidence rates are nominal between racial and ethnic groups, yet blacks have a significantly higher cerebrovascular disease death rate than whites. However, stroke mortality rates decreased from , and the mortality rate difference between minorities and whites was reduced by more than 60 percent by The lack of healthcare services is a contributing factor to high prevalence and death rates of heart disease. In 2012 Wicomico County residents experienced a percent greater rate of death from heart disease compared to Maryland statewide, while Dorchester County residents had a 9.07 percent greater rate of death from heart disease compared to Maryland. National Data Heart disease and stroke are major causes of illness and disability and are estimated to cost the nation hundreds of billions of dollars annually in health care expenditures and lost productivity. The total cost of cardiovascular disease is estimated at $448.5 billion annually (2008 estimate, AHRQ). Heart disease was ranked as the number one cause of death in the United States, causing 652,091 deaths in 2005 (AHRQ). 1 State Data Heart disease and stroke affect portions of the population in Maryland disproportionately based on gender, race and ethnicity. Improvements in treatment have reduced the mortality rate for heart diseases by 25 percent between 2000 and 2009 (reduced by 22 percent among whites and 1 Agency for Health Research and Quality. Accessed: 67

68 26 percent among blacks). 2 Although incidence rates have declined among all racial and ethnic groups in the state over the last several years, disparities among different racial/ethnic groups exist. White males have the highest prevalence rates of coronary heart disease (see Figure 1), while blacks have the highest death rate (see Figure 2), which suggests that minorities receive worse care, experience greater disease severity levels and, ultimately, worse health outcomes (MD DHMH, 2009). Figure 1. Prevalence of Coronary Artery Disease by Race and Gender, Maryland, In 2009, the death rate in Maryland for black males was 15 percent higher than white males and the death rate for black females was about 35 percent higher than white females. However, treatment in general is improving because over the last decade, diseases of the heart have resulted in about a quarter fewer deaths across Maryland (see Figure 2). Figure 2. Death Rate for Diseases of the Heart by Race, Maryland, Maryland Vital Statistics Administration. Annual Report (2009). 68

69 County Data The prevalence of coronary heart disease in Dorchester County is higher than the prevalence in the state of Maryland overall, whereas the prevalence of this disease in Wicomico County is significantly lower than for the state of Maryland (see Figure 3). Figure 3. Coronary Heart Disease Prevalence, Maryland, Dorchester County, Wicomico County, Although Wicomico County s prevalence for coronary heart disease was lower than the prevalence for the state of Maryland, the age-adjusted death rate for coronary heart disease was much higher than the state of Maryland at per 100,000 population and two times higher than the targeted rate of per 100,000 population for Healthy People 2020 (see Figure 4). Dorchester County s age-adjusted death rate for coronary heart disease at per 100,000 population was also much higher than the targeted rate for Healthy People 2020 but was only slightly higher than Maryland s age-adjusted death rate of per 100,000 population (See Figure 4). 3 Community Commons. Community Health Needs Assessment. Accessed: 69

70 Figure 4. Age-Adjusted Death Rate, Coronary Heart Disease Mortality (Per 100,000 Pop.) in Maryland, Dorchester County, Wicomico County, According to the Maryland State Health Improvement Process (SHIP, 2012), both Wicomico County and Dorchester County need to work on reducing deaths from heart disease. In 2012, the rate of heart disease deaths in Wicomico County was per 100,000 population, which is much higher than the rate of per 100,00 population in the state of Maryland overall (see Figure 5). There are also some racial disparities that exist between black and white residents with regard to the rate of heart disease deaths in both Wicomico and Dorchester Counties. Dorchester County residents experienced a lower rate of heart disease deaths compared to Wicomico County at per 100,000 population, but still fall short of the Maryland SHIP 2014 target of per 100,000 (See Figure 5). Maryland State Health Improvement Process in Wicomico County & Dorchester County, 2012 Figure 5. Maryland State Health Improvement Process (SHIP) Reduce Deaths from Heart Disease, Wicomico County, Dorchester County, Maryland Department of Health and Mental Hygiene. Maryland State Health Improvement Process (SHIP). (2012). Accessed: 70

71 Male residents had a higher rate of coronary heart disease mortality in both Dorchester County ( per 100,000 population) and Wicomico County ( per 100,000 population) compared to female residents of Dorchester County ( per 100,000) and Wicomico County ( per 100,000) (see Figure 6). Figure 6. Population by Gender, Coronary Heart Disease Mortality, Age-Adjusted Rate (Per 100,000 Pop.) in Maryland, Dorchester County, Wicomico County, There is no data available on coronary heart disease mortality among Asians, American Indians/Alaskan Natives, and Hispanics/Latinos in Dorchester County or Wicomico County. Based on the available data, black residents in both Dorchester County and Wicomico County die from coronary heart disease at higher rates than white residents (see Figure 7). Figure 7. Population by Race/Ethnicity, Coronary Heart Disease Mortality, Age-Adjusted Rate (Per 100,000 Pop.) in Maryland Dorchester, Wicomico,

72 STROKE / CEREBROVASCULAR DISEASE Impact A stroke, or cerebrovascular disease, sometimes called a brain attack, occurs when a clot blocks the blood supply to the brain or when a blood vessel in the brain bursts. Lifestyle changes and, in some cases, medication, can greatly reduce one s risk for stroke. Stroke can cause death or significant disability, such as paralysis, speech difficulties, and emotional problems. Some new treatments can reduce stroke damage if patients get medical care soon after symptoms begin (CDC, 2012). National Data Cerebrovascular disease, or stroke, is one of the top five leading causes of death in the United States. Heart disease is a risk factor for stroke. The risk of stroke can vary for different racial and ethnic groups. African Americans are at twice the risk of having a first stroke compared to whites; Hispanic Americans fall between the two. African Americans and Hispanics are more likely to die after suffering a stroke than whites (CDC, 2012). State Data Cerebrovascular disease, or stroke, is the third leading cause of death in Maryland. Unlike coronary heart disease, the prevalence of stroke in Maryland differs nominally among racial and ethnic groups, as well as across years (see Figure 8) (MD DHMH, 2009). Figure 8. Prevalence of Stroke by Race and Gender, Maryland,

73 Nonetheless, black residents had the highest cerebrovascular death rate in Maryland in 2008, at 45.1 compared to 38.3 per 100,000 for white residents (see Figure 9). Figure 9. Age-Adjusted Death Rate for Cerebrovascular Disease by Race, Maryland, 2008 Mortality rates for Maryland residents who suffered from stroke decreased from , during which time the rate decreased by 41.2 percent among blacks, by 35.3 percent among whites, and the mortality difference between the groups was reduced by 61.1 percent (see Figure 10) (MD Vital Statistics Administration, 2008). Figure 10. Age-Adjusted Stroke Mortality Rate by Race, Maryland,

74 County Data While mortality rates for stroke in Wicomico County have met the Healthy People 2020 target, the rates in Dorchester County have not. Dorchester County has an age-adjusted death rate for stroke mortality of per 100,000 population, which is much higher than the Healthy People 2020 target of 33.8 per 100,000 population (See Figure 11). Figure 11. Age-Adjusted Death Rate, Stroke Mortality (Per 100,000) in Maryland, Dorchester County, Wicomico County, The mortality rates for stroke in Wicomico County continued to decreased from 35.2 deaths per 100,000 population from to 28.2 deaths per 100,000 population from (see Figure 12). Age-Adjusted Death Rate due to Cerebrovascular Disease (Stroke) in Wicomico County, Figure 12. Age-Adjusted Death Rate due to Cerebrovascular Disease in Wicomico County, Peninsula Regional Medical Center. Creating Health Communities Community Dashboard. Heart Disease & Stroke. (2011). Accessed: 74

75 The stroke mortality rate for female residents of Wicomico and Dorchester Counties are slightly higher than stroke mortality rates for male residents (see Figure 13). Figure 13. Stroke Mortality Rate per 100,000 by Gender in Wicomico County and Dorchester County, Health disparities are present between racial/ethnic groups with regard to mortality rates for stroke. Black residents have the highest stroke death rate in Dorchester County at 60.3 per 100,000 population compared to white residents at per 100,000 population; and the rate for black residents of Wicomico County is per 100,000 population compared to white residents at per 100,000 population (see Figure 14). There is no significant difference in mortality rates for stroke between genders. Figure 14. Population by Race/Ethnicity, Stroke Mortality, Age-Adjusted Rate (Per 100,000) in Maryland, Dorchester County, Wicomico County, Centers for Disease Control and Prevention. Division for Heart Disease and Stroke Prevention: Interactive Atlas. Accessed: 75

76 Local Resources Heart Disease and Stroke The following organizations provide a variety of services to heart disease and stroke patients in the Adventist Behavioral Health Eastern Shore s Community Benefit Service Area: The Guerrieri Heart & Vascular Institute at Peninsula Regional Medical Center provides a comprehensive cardiac care program which is open to the community Programs such as Fitness Plus offer community exercise classes as part of the Peninsula Regional Medical Care outreach. The Wagner Wellness Mobile Health Van provides free services to the Delmarva area including coastal cardiac checks, women s heart checks, blood pressure screenings, and pulse oximetry testing. Women s Heart Program provides women with heart disease risk assessments and follow up. Examples of these assessments include: body mass index, fasting lipid profile, and body fat measurement. The Wicomico County Mended Hearts Chapter provides services to heart patients such as visiting programs, support group meetings and education meetings. Support is offered at the hospital, online, or phone visits. The American Heart Association serves residents in Wicomico and Dorchester counties by offering free screenings and educational materials. University of Maryland Shore Regional Health offers outpatient cardiovascular diagnostic and treatment services at Dorchester General Hospital, Memorial Hospital, and Shore Medical Office Pavilion. Inpatient services can be found at Memorial Hospital s accredited Primary Stroke Center. University of Maryland Shore Regional Health offers educational health and presentations on stroke prevention to interested community groups and organizations. 76

77 Chapter 4. Diabetes 77

78 Chapter 4. DIABETES Impact Diabetes Mellitus affects an estimated 25.8 million people in the United States, 8.3 percent of the total U.S. population, and of these, 7 million do not know they have the disease; it is the 7th leading cause of death. 1 Diabetes is usually a lifelong (chronic) disease in which there are high levels of sugar in the blood. There are three types of diabetes. Type 1 can occur at any age, but it is most often diagnosed in children, teens, or young adults. In this disease, the body makes little or no insulin. Type 2 accounts for 95 percent of those diagnosed with diabetes among adults. The third type is gestational diabetes, which develops and is diagnosed as a result of pregnancy. 2 Diabetes is a major cause of stroke, and is a leading cause of kidney failure, nontraumatic lower-limb amputations, and new cases of blindness among adults in the United States. Diabetes can lower life expectancy by up to 15 years and increases the risk of heart disease by 2 to 4 times. Overall, the risk for death among people with diabetes is about twice that of people of similar age without diabetes (CDC, National Diabetes Fact Sheet, 2011). Diabetes impacts diabetics and their families physically, financially, emotionally, in their home life, in their work, and in their day-to-day lives. Diet, insulin, and oral medication to lower blood glucose levels are the foundation of diabetes treatment and management. It is also important for educational programs and self-care practices to maintain control of diabetes, allowing individuals to lead normal lives. Key Takeaways Across the state of Maryland, the number of people diagnosed with diabetes has grown from 6.8 percent in 1999 to 9.5 percent in 2012, which continues to be above the national level. As obesity rates in American children continue to increase, type 2 diabetes, a disease that used to be seen primarily in adults over 45, is becoming more common in young people. From 2010 to 2011, the percentage of Wicomico County residents diagnosed with diabetes decreased from 11.8 percent to 9.1 percent. In Dorchester County, the prevalence of diabetes is 13.5 percent, which is much higher than the state s prevalence of 9.16 percent. In both Dorchester County and Wicomico County, black residents visit the Emergency Room for diabetes approximately three times more frequently than white residents. 1 American Diabetes Association. 2 Centers for Disease Control and Prevention. Diabetes Report Card

79 National Data Among U.S. seniors aged 65 and older, 10.9 million, or 26.9 percent, had diabetes in 2010; among people younger than 20, about 215,000 had either type I or type II diabetes (CDC, National Diabetes Fact Sheet, 2011). The number of people diagnosed with diabetes has risen from 1.5 million in 1958 to 18.8 million in 2010, an increase of epidemic proportions (see Figure 1). 3 Figure 1. Number and Percentage of U.S. Population with Diagnosed Diabetes, According to the National Diabetes Education Program, in 2010, 13.0 million men had diabetes (11.8 percent of all men ages 20 years and older) and 12.6 million women had diabetes (10.8 percent of all women ages 20 years and older) (see Figure 2). As obesity rates in American children continue to increase, Type II diabetes, a disease that used to be seen primarily in adults over 45, is becoming more common in young people. In the United States, compared to non-hispanic whites, Asian Americans have an 18 percent higher risk of diagnosed diabetes, Hispanics/Latinos have a 66 percent higher risk, and non-hispanic blacks have a 77 percent higher risk (NDEP, 2011). 3 National Diabetes Education Program. Diabetes and Pre-diabetes Statistics and Facts (2012). 79

80 Diagnosed and undiagnosed diabetes among people aged 20 years or older, United States, 2010 Group Age > 20 years Age < 65 years Men Women Number or percentage who have diabetes 25.6 million or 11.3% of all people in this age group 10.9 million or 26.9% of all people in this age group 13.0 million on 11.8% of all men aged 20 years or older 12.6 million or 10.8% of all women aged 20 years or older 15.7 million or 10.2% of all non-hispanic whites aged 20 years or older 4.9 million or 18.7% of all non-hispanic blacks aged 20 years or older Non-Hispanic whites Non-Hispanic blacks Figure 2. Diagnosed & Undiagnosed Diabetes among people age 20+ in the U.S., 2010 (Source: The growth of diabetes has been exponential over the past decade, as is the cost of treatment and time lost. The National Diabetes Education Program estimates that the total health care and related costs for the treatment of diabetes run about $174 billion annually in the United States. Of this total, $116 billion is spent on hospitalizations, medical care, and treatment supplies, while $58 billion covers indirect costs like disability payments, time lost from work, and premature death (NDEP, accessed 2013). State Data Maryland ranks 22 nd in the country for diabetes based on data from (America s Health Rankings, United Health Foundation, 2013). Across the state of Maryland, the number of people ever medically diagnosed with diabetes has grown from 6.8 percent in 1999 to 9.5 percent in 2012, which continues to be above the national level. 4 In 2008, the average prevalence of diagnosed diabetes among white Marylanders was 7.5 percent and 12.3 percent among black Marylanders (MD DHMH). Black females had almost double the diabetes rates of white females at 12.5 percent and 6.8 percent, respectively (MD DHMH, 2008). In 2011, 1,272 Maryland residents lost their lives to diabetes. 5 From 2004 to 2008, black adults of all ages had significantly higher rates of diagnosed diabetes compared to non- Hispanic whites (MD DHMH, Maryland Chartbook of Minority Health, 2009) (see Figure 3). 4 MD Department of Health and Mental Hygiene. Diabetes.pdf. Accessed MD Department of Health and Human Services. Services/Number-of-Diabetes-Deaths-among-Maryland-Residents/smru-f5wc. Accessed

81 Figure 3. Percent of Adults Age Reporting Diagnosed Diabetes by Race/Ethnicity, Maryland, (Source: Maryland BRFSS Data, ) Among seniors aged 65 or older, non-hispanic blacks, Hispanics, and other non-hispanic non-white groups all showed higher estimates for rates of diagnosed diabetes than non- Hispanic whites from (see Figure 4). Figure 4. Percent of Adults Age 65 or older Reporting Diagnosed Diabetes by Race/Ethnicity, Maryland, (Source: Maryland BRFSS Data, ) 81

82 County Data Wicomico County In 2011, 9.1 percent of adult Wicomico County residents had been diagnosed with diabetes, which is a slight decrease from the previous two years (see Figure 5). Adults with Diabetes Time Series Data, Wicomico County Figure 5. Percent of Adults with Diabetes, Wicomico County, The age-adjusted death rate due to diabetes from was 17.5 deaths per 100,000 population in Wicomico County, which is an improvement from 30.1 deaths per 100,000 population due to diabetes from (see Figure 6). Age-Adjusted Death Rate due to Diabetes Time Series Data, Wicomico County, Figure 6. Age-Adjusted Death Rate due to Diabetes in Wicomico County, Peninsula Regional Medical Center. Creating Healthy Communities Community Dashboard. Diabetes. (2013). Accessed: 82

83 According to the Maryland State Health Improvement Process (SHIP, 2012), reducing the rate of diabetes-related emergency department visits was one of the objectives for Wicomico County. Although the rate of emergency department visits for diabetes per 100,000 population decreased from in 2011 to in 2012, the rate is far higher than the rate of per 100,000 population in Maryland. 7 Additionally, disparities exist between racial groups. Black residents of Wicomico County experienced a rate of 1,020.5 per 100,000 population emergency department visits for diabetes, which is almost three times higher than white Wicomico County residents at per 100,000 population. Dorchester County According to Centers for Disease Control and Prevention, the prevalence of diabetes in Dorchester County was 13.5 percent of the county s population. 8 This is much higher than the diabetes prevalence in Maryland of 9.16 percent or the nation s prevalence of 8.95 percent. 9 Furthermore, the diagnosed diabetes incidence rate is 14.0 per 1,000 population in Dorchester County. 10 Figure 7. Maryland State Health Improvement Process (SHIP) Reduce Diabetes-related ED Visits Goal, Dorchester County, Maryland State Health Improvement Process has set a targeted rate of ED visits for diabetes at per 100,000 population for Maryland by 2014 (see Figure 6). The rate in Dorchester County increased from to per 100,000 population from 2011 to Black residents of Dorchester County continue to experience an even higher rate at 1,427.9 per 100,000 population compared to white residents of Dorchester County at per 100,000 population (see Figure 7). 7 Maryland Department of Health and Mental Hygiene. Maryland State Health Improvement Process (SHIP) Wicomico County. (2012). Accessed: 8 Centers for Disease Control and Prevention. Diabetes Public Health Resource. Diabetse Interactive Atlases. Diagnosed Diabetes Prevalence. (2013). Accessed: 9 Community Commons. Community Health Needs Assessment Full Health Indicators Report. Health Outcomes Diabetes Prevalence. (2010). Accessed: 10 Centers for Disease Control and Prevention. Diabetes Public Health Resource. Diabetes Interactive Atlases. Diagnosed Diabetes Incidence. (2013). Accessed: 11 Maryland Department of Health and Mental Hygiene. Maryland State Health Improvement Process (SHIP) Dorchester County. (2012). Accessed: 83

84 Local Resources Diabetes The following organizations provide a range of diabetes-related services in the Adventist Behavioral Health Eastern Shore s Community Benefit Service Area: The American Diabetes Association provides diabetes education in eight Eastern Shore counties. University of Maryland Center for Diabetes and Endocrinology, located at Memorial Hospital, is the only diabetes specialty clinic on Maryland s Eastern Shore. Peninsula Regional Medical Center offers a variety of programs and supportive services including a Pediatric and Gestational program. In addition, the Center offers: a Diabetes Education Program, a 5 week Diabetes Self-Management Program which includes education in the areas of nutrition, foot care, blood glucose monitoring and exercise. Free Diabetes support groups are also offered. The Medical Nutrition Therapy gives diabetics the opportunity to develop a personalized self-management plan with a Registered Licensed Dietitian and may include instruction for blood glucose monitoring, insulin injections, and other injectable medications; The Tri-County Diabetes Alliance is a collaboration of healthcare organizations in Somerset, Wicomico and Worcester counties dedicated to assisting and educating the community about diabetes. Among the services offered are educational presentations, counseling, and free screenings to diabetics and people who may be at risk for developing diabetes. Eastern Shore partners of the Tri-County Diabetes Alliance include, but are not limited to, the American Diabetes Association, McCready Health Foundation, Peninsula Regional Medical Center, Wicomico County Health Department, and University of Maryland Eastern Shore. Lifestyle Balance Program is a 16-week educational program for diabetics that focus on healthy eating, physical activity, and weight-loss. 84

85 Chapter 5. Obesity 85

86 Chapter 5. OBESITY Impact Obesity is defined as having a Body Mass Index (BMI) that is greater than or equal to 30, while being overweight is defined as having a BMI of Obesity has been linked to a number of diseases including diabetes, colorectal cancer, kidney cancer, breast cancer, and many types of cardiovascular disease (Cancer.gov, 2012). Childhood obesity is also on the rise due to the amount of sugary drinks and high energy foods that have become so easily available (CDC, 2013). Key Takeaways Approximately 66 percent of Maryland adults are overweight or obese, with men more likely to be overweight or obese than women, and black residents more likely to be overweight or obese than white residents. Adults with no college education and with a household income of less than $75,000 are significantly more likely to be overweight or obese. In Wicomico County, 71.9 percent of the adult residents were overweight or obese. The percentage of obese youth ages in Dorchester County was percent higher, and in Wicomico County it was percent higher, than the percentage statewide. The number of recreational facilities in Dorchester and Wicomico Counties is far behind the national benchmark of 16 per 100,000 population, with only 4 recreational facilities in Dorchester County, and 10 recreational facilities in Wicomico County. Both Dorchester County and Wicomico County residents have a level of physical inactivity much greater than the state of Maryland baseline. National Data Sixty-eight percent of all Americans are overweight 1 and approximately 147 billion dollars are spent on obesity related diseases every year. 2 The prevalence of obesity among adolescents aged 12 to 19 more than tripled from 1980 to 2006, from 5 percent to 17 percent. 3 Obese youth are at risk for factors associated with cardiovascular disease (e.g., high cholesterol or high blood pressure), bone and joint problems, sleep apnea, and poor self-esteem. Obese youth are at an increased risk of becoming obese adults and, therefore, are at risk for the associated adult health problems, such as heart disease, type 2 diabetes, stroke, cancer, and osteoarthritis. 4 State Data According to the Maryland Behavioral Risk Factor Surveillance System (BRFSS, 2010), nearly 2.7 million, or about 66.1 percent of Maryland adults, were classified as overweight or obese. Men were more likely to be classified as overweight or obese (73.4 percent) than women ( Centers for Disease Control and Prevention. Accessed Centers for Disease Control and Prevention. Accessed Freedman D.S., Zuguo M., Srinivasan S.R., Berenson G.S., Dietz W.H. (2007). Cardiovascular Risk Factors and Excess Adiposity among Overweight Children and Adolescents: The Bogalusa Heart Study. Journal of Pediatrics, 150 (1): World Health Organization. (2009). Obesity. 86

87 percent), and black residents were more likely to be overweight or obese (74.0 percent) than white residents (62.9 percent); these differences are statistically significant. Adults with no college education and with a household income of less than $75,000 were significantly more likely to be overweight or obese. Figure 1. Distribution of Body Mass Index (Obese = 30.0% and above) in Maryland (MD BRFSS, 2007) 5 According to the Maryland State Department of Education s Maryland Youth Risk Behavior Survey (YRBS, 2009), the percentage of Maryland youth who are overweight or obese has not changed significantly between 2005 and 2009 (see Figure 2). One in 4 Maryland youth is overweight or obese. Figure 2. Overweight/obese Maryland Youth and Weight Loss Attempt, (MSDE, YRBS, 2009) 5 Montgomery County MD Department of Health and Human Services. Accessed

88 Although there are significantly more overweight or obese males than females, significantly more females describe themselves as overweight and are trying to lose weight (see Figures 3 and 4). Figure 3. Overweight, obesity, and weight loss among Maryland males and females (MSDE, YRBS, 2009) Figure 4. Weight Loss Methods, Maryland Youth (MSDE, YRBS, 2009) 88

89 Fruit, vegetable, and milk consumption among Maryland youth has remained steady between 2005 and There is little variation between males and females in fruit and vegetable consumption; however, significantly more males than females drink milk (see Figure 5). Figure 5. Fruit, Vegetable, Milk, and Soda pop Consumption among Maryland Youth, 2009 (Source: MSDE, YRBS, 2009) 89

90 County Data Wicomico County In 2011, 71.9 percent of the adult residents in Wicomico County were overweight or obese (see Figure 6), and 43.5 percent were obese (see Figure 7). The percentage of overweight and obese adults is an indicator of the overall health and lifestyle of a community. Wicomico County s high percentage of obese residents misses the Healthy People 2020 target by over 13 percent and continues to rise every year. Adults who are Overweight or Obese in Wicomico County, Figure 6. Adults who are Overweight or Obese in Wicomico County, Adults who are Obese in Wicomico County, Figure 7. Adults who are Obese in Wicomico County, Peninsula Regional Medical Center. Creating Healthy Communities Community Dashboard. Recreation and Fitness Facilities. (2013). Accessed: 90

91 In 2012, 14.9 percent of youth (ages 12-19) in Wicomico County were obese, compared to the Maryland State Health Improvement Process 2014 target of 11.3 percent. Among all racial and ethnic groups in Wicomico County, black residents have the highest percentage of youth who are obese at 19.2 percent, followed by Hispanics at 15.5 percent, compared to Asian/Pacific Islanders (11.3 percent) and White residents (12.6 percent) (see Figure 8). Maryland State Health Improvement Process (SHIP) Goal for Wicomico County, 2012 Figure 8. Maryland State Health Improvement Process (SHIP) Objective to Reduce the Proportion of Young Children and Adolescents who are Obese, Wicomico County, The level of physical inactivity in Wicomico County was 28 percent in 2009, which was higher than the Maryland level of 24 percent and the national benchmark of 21 percent. The trend of physical inactivity in Wicomico County continued to rise from (see Figure 9). In 2010, the leisure-time physical inactivity prevalence for Wicomico County was at 28.9 percent. 8 Figure 9. Physical Inactivity in Wicomico County, MD compared to Maryland and United States, Maryland Department of Health and Human Services. Maryland State Health Improvement Process. Wicomico County. (2012). Accessed: 8 Centers for Disease Control and Prevention. Diabetes Public Health Resource. Diabetes Interactive Atlases. Leisure-time Physical Inactivity Prevalence by County. (2010). Accessed: 9 County Health Rankings & Roadmaps. Wicomico County Health Outcomes. Accessed: 91

92 When broken down by gender, 26.4 percent of male and 31.2 percent of female Wicomico County residents do not engage in leisure-time physical activity. 10 Despite the high percentage of physical inactivity among Wicomico County residents, there are still higher percentages of adults engaging in moderate physical activity or regular physical activity. In 2011, 50.4 percent of adults 18 and older participated in at least 150 minutes of physical activity or at least 75 minutes of vigorous physical activity per week (see Figure 10). Another 37.5 percent engaged in moderate physical activity for at least 30 minutes, five days per week in 2010 (see Figure 11). Adults ages were more likely to engage in regular physical activity and adults ages were more likely to engage in moderate physical activity. Figure 10. Adults Engaging in Regular Physical Activity by Age in Wicomico County, Figure 11. Adults Engaging in Moderate Physical Activity by Age in Wicomico County, Centers for Disease Control and Prevention. Diabetes Public Health Resource Diabetes Interactive Atlases. Leisure-time Physical Inactivity Prevalence by Gender by County. (2010). Accessed: 92

93 Access to recreational facilities in Wicomico County is very poor, with only 10 in the entire county. 11 In 2009, there were only 0.12 recreational facilities per 1,000 population, which is a slight decrease since 2007 (see Figure 12). Recreation and Fitness Facilities per 1,000 population in Wicomico County, 2009 Figure 12. Recreation and Fitness Facilities per 1,000 population in Wicomico County, Dorchester County In 2012, 18.1 percent of the youth (ages 12-19) were obese in Dorchester County, which is far from meeting the Maryland SHIP 2014 target of 11.3 percent. Among youth in Dorchester County, black residents have the highest percentage of obesity at 22.3 percent compared to Asian/Pacific Islander (16.3 percent), Hispanic (15.2 percent), and white (16.5 percent) residents (see Figure 13). Maryland State Health Improvement Process (SHIP) Goal for Dorchester County, 2012 Figure 13. Maryland State Health Improvement Process (SHIP) Objective to Reduce the Proportion of Young Children and Adolescents who are Obese, Dorchester County, County Health Rankings & Roadmaps. Access to Recreational Facilities Data. (2013). Accessed: 12 Maryland Department of Health and Human Services. Maryland State Health Improvement Process. Dorchester County. (2012). Accessed: 93

94 Local Resources Obesity Services and resources to prevent or reduce obesity are often incorporated within other programs addressing diabetes, heart disease, and cancer. In Adventist Behavioral Health Eastern Shore s service area, there are local efforts in schools, clinics, and recreational centers to reduce and prevent obesity and encourage healthy lifestyles, including, but are not limited to: The Chronic Disease Prevention Program in Wicomico County educates the community on the importance of eating and begin physically active. The Maryland Nutrition and Physical Activity Plan have schools adopting plans to implement policies in Dorchester County. Both Dorchester and Wicomico Counties have the Women, Infants, and Children (WIC) program also addresses obesity prevention through nutrition education. Shore Health System in Easton has a Nutrition Center which provides nutrition counseling including weight control. Peninsula Region Medical Center works with the Delmarva Bariatric and Fitness Center providing a fitness center, free seminars, weight management programs and support groups. Approximately six support groups in Wicomico County specifically address weight addressing such core issues as food addiction, self esteem, and lifestyle. Racial & ethnic Disparities in Salisbury, MD address obesity providing educational materials. 94

95 Chapter 6. Asthma 95

96 Chapter 6. ASTHMA Impact Asthma is a chronic inflammatory disease of the small airways in the lungs that affects people of all ages, races, ethnicities, and genders, and is known to cause attacks of impaired breathing. This disease has varying degrees of severity, ranging from mild to life threatening. Not much is understood about preventing asthma from developing, however, the means for controlling and preventing symptoms are well established. Children are more sensitive than adults to particulate matter and other irritants that can trigger an asthma attack due to smaller and narrower size of their respiratory pathways. Therefore, poor air quality has a greater impact on children s respiratory systems. Key Takeaways Asthma prevalence increased among both adults and children in Maryland from 2000 to 2009, with young children (ages 0-4) brought to the emergency department for asthma far more often than adults. In Maryland, the asthma prevalence rate for male children was significantly higher than female children, but adult females had significantly higher rates than adult males. Adults in Maryland with lower annual household incomes had a significantly higher asthma prevalence compared to adults with higher annual household incomes, and asthma emergency department visits for blacks were five times the rate of whites. In Wicomico County, rates for Emergency Department visits for asthma were higher than for the state of Maryland. In Dorchester County, rates of Emergency Department visits for asthma were 1.5 times higher than the Emergency Department visit rate for the state of Maryland. Black residents in both Wicomico County and Dorchester County had asthma related Emergency Department visit rates significantly higher than white residents in National Data Asthma prevalence has seen a significant increase from 3.5 percent of the U.S. population in 1980 to 8.2 percent of the U.S. population in 2009 (24.6 million people) (CDC/NCHS, National Health Interview Survey). Although asthma prevalence is on the rise, asthma attack prevalence has remained relatively stable between 3.9 percent and 4.3 percent during the period from 1997 to 2009 (see Figure 1). 96

97 Figure 1. Asthma Period Prevalence, Asthma Attack Prevalence, and Current Asthma Prevalence, All Ages, United States, Nationally, there are noticeable differences in asthma prevalence among population subgroups (see Figure 2). Asthma prevalence is higher among females (9.3 percent) than males (7.0 percent); higher among children and adolescents (9.6 percent) than adults ages 18 and older (7.7 percent); higher among blacks (11.1 percent) than whites (7.8 percent) and highest among Puerto Ricans (16.6 percent); higher among people below the poverty line (11.6 percent) than those at 200 percent above the poverty line and above (7.3 percent); and higher in the Northeast United States (9.3 percent) than any other region of the country (CDC/NCHS, National Health Interview Survey, 2009). 97

98 Figure 2. Prevalence of Current Asthma Prevalence, by Selected Characteristics, United States, 2009 State Data Adults: In 2009, the current asthma prevalence was an estimated 9.1 percent, or approximately 389,000 Maryland adults aged 18 or older, compared to 8.4 percent of adults in the United States (see Figure 3) (BRFSS, ). This is an increase in asthma prevalence among adults in Maryland of approximately 25 percent since Figure 3. Trend in Current Asthma Prevalence among Adults in Maryland vs. United States, (Source: Maryland BRFSS ; CDC BRFSS ) 1 MD Department of Health and Mental Hygiene, Family Health Administration, Maryland Asthma Control Program. Asthma in Maryland

99 Between 2007 and 2009, the current asthma prevalence among females (11.1 percent) was significantly higher than among males (6.6 percent) (see Figure 4). Figure 4. Current Asthma Prevalence among Adults by Sex, Maryland, Between 2007 and 2009, adults reporting an annual household income in the lowest categories (less than $15,000 and between $15-$24,999) had a significantly higher current asthma prevalence (13.9 percent and 13.4 percent) compared to adults reporting higher annual household incomes (see Figure 5). Figure 5. Current Asthma Prevalence among Adults by Annual Household Income, Maryland,

100 Children: There was an increase in lifetime asthma prevalence in Maryland children from 2001 to 2009 (see Figure 6). In 2009, 17.1 percent of Maryland children under the age of 18 (more than 228,000) had been told by a health professional at some point during their lifetime that they had asthma, compared to approximately 13.9 percent of children (10.2 million) in the United States (BRFSS, 2009). Figure 6. Trend in Current Asthma Prevalence among Children ages 0-17, Maryland vs. United States, (Source: Maryland BRFSS ; CDC BRFSS ; Note: Survey question changed in 2005 so data from are not comparable to data from ; Note: Each year the number of states collecting data on asthma prevalence in children has been between 22 and 37 states.) The current asthma prevalence rate for male children (11.7 percent) was significantly higher than for female children (8.6 percent) in Maryland between 2007 and 2009 (see Figure 7). Figure 7. Current Asthma Prevalence among Children Ages 0-17 by Sex, Maryland,

101 Between 2007 and 2009 the current asthma prevalence was significantly higher among non-hispanic black children (14.9 percent) than among non-hispanic white children (7.5 percent) (see Figure 8). Figure 8. Current Asthma Prevalence among Children Ages 0-17 by Race, Maryland, Hospital Utilization: Individuals with asthma can generally manage their condition through the avoidance of triggers, appropriate use of medications, and appropriate care by a primary care provider, with specialty consultation as needed. Emergency department (ED) visits and/or hospitalizations occur when individuals with asthma develop symptoms that cannot be managed at home. This may be due to a lack of appropriate care or unsuccessful self-management (MD DHMH, Asthma in Maryland, 2011). In Maryland, asthma ED visits for blacks were five times the rate of whites (160.4 per 10,000 compared to 31.8 per 10,000), and young children (ages 0-4) were brought to the ED for asthma far more often than older children or adults (see Figure 9) (HSCRC, 2009). Figure 9. Asthma Emergency Department Visit Rates by Race, Sex, and Age, Maryland,

102 County Data Wicomico County In 2009, 9.2 percent of adult residents in Wicomico County were estimated to have been diagnosed with asthma in their lifetime, and 7.4 percent (approximately 5,152 adults) reported currently having asthma (see Figure 10) (MD BRFSS, 2009). There is little reliable county level data on the prevalence of asthma in children, despite it being one of the most common illnesses among children. Figure 10. Asthma Prevalence among Adults, Wicomico County, Maryland, In 2011, the percent of adult residents in Wicomico County who had been diagnosed with asthma in their lifetime increased from 9.2 percent (in 2009) to 11.5 percent (see Figure 11). Percent of Adults with Asthma in Wicomico County, Figure 11. Percent of Adults with Asthma in Wicomico County, , BRFSS Maryland Department of Health and Mental Hygiene. Asthma in Wicomico County. (2011). Accessed: 102

103 The percent of children in Wicomico County with asthma decreased from 19.2 percent to 10.2 percent from 2009 to Yet, in 2011, the percent of children with asthma increased to 18.5 percent (See Figure 12, with note). Percent of Children with Asthma in Wicomico County, Figure 12. Percent of Children with Asthma in Wicomico County, , BRFSS Note: The BRFSS 2011 prevalence data should be considered a baseline year for data analysis and is not directly comparable to previous years of BRFSS data because of the changes in weighting methodology and the addition of the cell phone sampling frame. 3 Of the 11.5 percent of adults with asthma, female Wicomico residents have a higher percentage of asthma than male Wicomico residents (See Figure 13). Figure 13. Adults with Asthma by Gender in Wicomico County, 2011, BRFSS Peninsula Regional Medical Center. Creating Health Communities Community Dashboard. Respiratory Diseases. (2011). Accessed: 103

104 The rates of Emergency Department visits for asthma were higher for Wicomico County than for the state of Maryland. In addition, there was a disparity in the rate among racial/ethnic groups in Wicomico County (2009). Black residents of Wicomico County had an asthma ED visit rate about 4.2 times higher than white residents in 2009 (see Figure 14). Hospitalization rates due to asthma showed a similar trend. Figure 14. Asthma Emergency Department Visit Rates by Race, Wicomico County, Maryland, In 2009, Wicomico County fell far short of the Healthy People 2010 goals for asthma Emergency Department visits, for all age groups. For example, the Healthy People goal for asthma ED visits for children aged 0-4 was 80.0 per 10,000; the rate in Wicomico County for this age group was per 10,000. Asthma ED visit rates were similarly too high for the 5-64 and 65+ age groups. (see Figure 15). Figure 15. Asthma Emergency Department Visits Rates by Age, Wicomico County, Maryland,

105 In 2012, Wicomico County had an asthma Emergency Department visit rate of 84.5 per 10,000 population (SHIP, 2012). Due to this high rate, the Maryland State Health Improvement Process in Wicomico County is striving to reduce Emergency Department visits for asthma to the Maryland SHIP 2014 target of 49.5 Emergency Department visits for asthma per 10,000 population (See Figure 16). Black Wicomico County residents had a disproportionately higher rate than any other racial/ethnic group. Maryland State Health Improvement Process Goal for Wicomico County, 2012 Figure 16. Rate of Hospital Emergency Department Visits for Asthma in Wicomico County, MD, On average, the costs of Emergency Department visits due to asthma were lower in Wicomico County than in the state of Maryland for both children and adults (see Figure 17). Figure 17. Costs per Emergency Department Visit for Asthma, by Age, Wicomico County, Maryland, Maryland Department of Health and Mental Hygiene. Maryland State Health Improvement Process (SHIP) Wicomico County. (2012). Accessed: 105

106 Dorchester County In 2009, 16.2 percent of adult residents in Dorchester County were estimated to have been diagnosed with asthma in their lifetime, and 11.4 percent (approximately 2,385 adults) reported currently having asthma (see Figure 18) (MD BRFSS, 2009). There is little reliable Dorchester County level data on the prevalence of asthma in children, despite it being one of the most common illnesses among children. Figure 18. Asthma Prevalence among Adults, Dorchester County, Maryland, The rates of Emergency Department visits for asthma in Dorchester County were 1.5 times higher than the Emergency Department visit rate for asthma for the state of Maryland. In addition, there was a disparity in the rate among racial/ethnic groups in Dorchester County (2009). Black residents of Dorchester County had an asthma ED visit rate about 5.0 times higher than white residents in 2009 (see Figure 19). However, compared to the state of Maryland, Dorchester County was higher in asthma Emergency Department visit rates for both race categories. Hospitalization rates due to asthma showed a similar trend. 5 Maryland Department of Health and Mental Hygiene. Asthma in Dorchester County. (2011). Accessed: 106

107 Figure 19. Asthma Emergency Department Visit Rates by Race, Dorchester County, Maryland, Dorchester County did not meet the Healthy People 2010 goals for asthma Emergency Department visits for the 0 to 4 or 5 to 64 age groups in Rates based on the few asthma Emergency Department visits for older adults in Dorchester County are unstable and are not reported (see Figure 20). Figure 20. Asthma Emergency Department Visit Rates by Age, Dorchester County, Maryland, Healthy People 2010, In 2012, Dorchester County s Emergency Department visits for asthma was at a high 98.0 per 10,000 population (See Figure 21). It is more than 1.5 times as high as the rate of Emergency Department visits for asthma in the state of Maryland. The Maryland SHIP 2014 target rate is 49.5 per 10,000. The rate for Non-Hispanic black residents in Dorchester County is three times higher than non-hispanic white residents in Dorchester County. 107

108 Maryland State Health Improvement Process (SHIP) Goal for Dorchester County, 2012 Figure 21. Rate of Hospital Emergency Department Visits for Asthma, Dorchester County, MD, On average, the costs of Emergency Department visits due to asthma were much higher in Dorchester County than in the state of Maryland for both children and adults (see Figure 22). Figure 22. Costs Per Emergency Room Visit for Asthma, Dorchester County, Maryland, Maryland Department of Health and Mental Hygiene. Maryland State Health Improvement Process (SHIP) Dorchester County. (2012). Accessed: 108

109 Local Resources - Asthma There are several educational and community health services offered in the Adventist Behavioral Health Eastern Shore s Community Benefit Service Area to address the issue of adults and children suffering from asthma: The Asthma and Allergy Foundation provides educational materials, parental training, and support groups to families of children with asthma. Peninsula Regional Medical Center provides educational programs such as the Better Breathers Club, a free support group for adults with asthma and other respiratory problems, and the American Lung Association s Open Airways Program. Peninsula Regional Medical Center also sponsors community events for children with asthma including Camp Huff & Puff and an overnight stay at the Salisbury Zoo for children with asthma. 109

110 Chapter 7. Influenza 110

111 Chapter 7. INFLUENZA Impact Influenza, commonly known as the flu, is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe illness, and at times can lead to death. Some people, such as young children, the elderly, and people with certain health conditions, are at high risk for serious flu complications. Influenza viruses are constantly changing. When a non-human (novel) influenza virus gains the ability for efficient and sustained human-to-human transmission and spreads globally, an influenza pandemic occurs (CDC, 2013). Key Takeaways Flu-related death rates in Maryland and in Montgomery County have been steadily decreasing, likely due to an increased awareness of flu shots and prevention efforts. However, there are still many Maryland residents who do not receive the flu shot, and there are significant differences among various sub-populations. An estimated 46 percent of Maryland children did not receive an annual seasonal flu vaccination: male children, black children, and children from households earning $15,000 to $50,000 annually were less likely to receive flu shots compared to female children, white children, and children from higher income families. An estimated 57 percent of Maryland adults did not receive a flu shot in the previous year: males, blacks, and those without health care coverage were significantly less likely to receive a flu shot compared to females, whites, and those with health coverage. In Wicomico County, approximately 47.5 percent of adults 65 years and older received an influenza vaccine which was significantly lower than the national health target of 90 percent. Under the immunization program, immunizations were provided in Dorchester County schools and at the Health Department; however, there were 6 deaths related to influenza and pneumonia. National Data According to the Centers for Disease Control and Prevention, in April 2009, H1N1 or swine flu broke out and quickly spread to more than 70 countries including the United States. The CDC also reports that between April and October of 2009, 22 million Americans contracted the virus, 98,000 required hospitalization, and about 3,900 people died from H1N1-related causes (CDC, 2012). Symptoms of H1N1 and the seasonal flu are very similar, and testing is the only way to know which influenza strain an individual has. Outside factors may increase the risk of flu epidemics in the near future, including the effects of global warming, increasing international travel, vectors already present in the United States, increasing importation of wild life (the United States is the world s largest importer of wild life) and the potential of bioterrorism (Healio, Infectious Disease News, 2012). 111

112 Flu season varies, but it normally starts in the winter and goes until spring. During the past 30- year period, flu activity most often peaked in February (14 seasons, or 47 percent of the time), followed by January and March (5 seasons each, or 17 percent of the time), and December (4 seasons, or 13 percent of the time) (see Figure 1). Peak Month of Flu Activity through Figure 1. Peak Month of Flu Activity, through The peak month of flu activity is the month with the highest percentage of respiratory specimens testing positive for influenza virus infection (WHO, 2012). The CDC estimates that 65 percent of seasonal flu-related deaths and more than 60 percent of flu-related hospitalizations in the United States each year occur in people ages 65 or older. 1 Figure 2 illustrates the percentage of outpatient visits for influenza-like illness from 2002 through 2013 flu seasons (CDC, Flu View, ). 1 Centers for Disease Control and Prevention. Flu View. Accessed 2013: 112

113 Figure 2. Percentage of Visits for Influenza-like Illness Reported by the U.S. Outpatient Influenza-like Illness Surveillance Network, through (selected seasons) State Data Incidence/Prevalence: Compared to previous influenza seasons, the influenza season was mild; the spread of influenza in Maryland was classified as sporadic, meaning there were smaller numbers of laboratory-confirmed influenza cases, and no increase in cases from the previous flu season (DHMH, 2012). The peak of influenza activity occurred between the middle of February and the end of March. The number of hospitalizations reported to MD DHMH was lower than previous years, as was the number of influenza-associated outbreaks. No pediatric deaths associated with influenza were reported. Only about 25 percent of specimens tested at the MD DHMH State Laboratories Administration were positive, and most of the positive cases were Type A (H3N2) seasonal influenza (see Figure 3) %20Summary.pdf 113

114 Figure 3. Number and Percentage of Positive Influenza Test Results, Maryland, 2012 Flu Season (DHMH) Death rates that have been linked to flu in the state of Maryland have been steadily decreasing, likely due to an increased awareness of flu shots and prevention efforts. However, there are still many Maryland residents who do not receive the flu shot, and there are significant differences among various sub-populations. Vaccination: An estimated 46.3 percent of Maryland children did not have a seasonal flu vaccination in the past year, and this percentage was greater among male children (47.6 percent) than female children (44.7 percent) (Maryland BRFSS, 2010 Report). The percentage of black children who did not have a seasonal flu vaccination in the past year was also significantly greater than that of white children (50.2 percent versus 43.7 percent) (see Figure 4). Figure 4. Percent of Maryland Children who did Not Have a Seasonal Flu Vaccination in the Past Year, by Gender (Left), and by Race (Right), 2010 (Source: Maryland BRFSS) 114

115 Children from households earning $15,000 to $24,999, as well as children in households with less than a college degree, were more likely to not have had a seasonal flu vaccination (see Figure 5). Figure 5. Percent of Maryland Children who did Not Have a Seasonal Flu Vaccination in the Past Year, by Age, Household Education, and Income, 2010 (Source: Maryland BRFSS) An estimated 57.0 percent of Maryland adults reported that they did not have a flu shot in the past year, with the percentage of men who did not have a flu shot being significantly greater than the percentage of women (60.3 percent versus 54.0 percent), and the percentage of black residents who did not have a flu shot being significantly greater than that of white residents (63.0 percent versus 52.6 percent) (see Figure 6). Figure 6. Percent of Maryland Adults who did Not Have a Flu Shot in the Past Year, by Gender (Left) and by Race (Right), 2010 (Source: Maryland BRFSS, 2010 Report) Adults ages were significantly more likely to not have had a flu shot than seniors 65 and older (66.8 percent versus 31.3 percent), and adults with an income of less than $25,000 were also more likely to not have had a flu shot in the past year (see Figure 7). Additionally, 115

116 Marylanders without health coverage were significantly more likely not to receive a flu shot than those with health coverage (81.7 percent versus 53.7 percent). Figure 7. Percent of Maryland Adults who did Not Have a Flu Shot in the Past Year, by Age, Education, and Income, 2010 (Source: Maryland BRFSS) County Data Wicomico County Statistics on influenza and pneumonia are frequently reported together, as pneumonia is frequently a complication of influenza. For 2009, influenza and pneumonia were ranked as the 7th leading cause of death among Wicomico County residents. 3 However, overall deaths due to influenza and pneumonia have decreased steadily in Wicomico County from (see Figure 8). Age-Adjusted Death Rate due to Influenza and Pneumonia, Wicomico County, Figure 8. Age-Adjusted Death Rate due to Influenza and Pneumonia Time Series Data, Wicomico County, Wicomico County Health Department Report Card. (2010). Accessed: 4 Peninsula Regional Medical Center. Creating Health Communities Community Dashboard. (2011). Accessed: 116

117 The CDC recommends annual vaccinations to prevent the spread of influenza. In Wicomico County, the rate for adults who are 65 and older who received an influenza vaccination in the past year is considerably low. In 2011, approximately 47.5 percent of adults 65 and older in Wicomico County received an influenza vaccination. 4 This rate does not meet the Healthy People 2020 national health target of 90.0 percent. 4 Pneumonia is the leading cause of vaccine-preventable death and illness in the United States. The pneumococcal vaccine is very effective at preventing severe disease, hospitalization, and death. The CDC recommends the current vaccine for adults ages 65 years and older. In 2011, Wicomico County had 61.8 percent of adult residents ages 65 years and older who have ever received a pneumonia vaccine. 4 This rate is slightly decreasing over time (See Figure 9). In order to meet the Healthy People 2020 national health target, Wicomico County must raise their rate to 90.0 percent. Adults 65+ with Pneumonia Vaccination in Wicomico County, Figure 9. Adults 65 and older with Pneumonia Vaccination Time Series Data, Wicomico County, Dorchester County Based on the Maryland Vital Statistics Annual Report, there were 6 deaths related to influenza and pneumonia in Dorchester County in Dorchester County has an immunization program that provides annual influenza immunizations ensuring that adults and children in Dorchester County are immunized appropriately. According to the Dorchester County Health Department Annual Report, under the immunization program, 217 children received required immunizations, 990 seasonal flu vaccines were administered in schools. Further, 736 seasonal flu vaccines, 30 pneumonia vaccines, and 106 Hepatitis B vaccines were administered at the Health Department. 5 5 Harrell, R. Dorchester County Health Department Annual Report. (2012). Accessed: 117

118 Local Resources Influenza Influenza is considered a high-priority public health problem particularly during flu season. Many clinics and other community outreach services are offered especially during peak flu season months including: The Community Health Services Division of Wicomico County Health Department provides influenza immunizations to county residents of all ages. Peninsula Regional Medical Center provides influenza prevention shots through their annual Drive-Thru Flu Clinic. Community members must be 13 years of age or older in order to obtain a vaccination. Local healthcare providers, primary care physicians, and pharmacies provide influenza vaccinations for community members of all ages. 118

119 Chapter 8. HIV/AIDS 119

120 Chapter 8. HIV/AIDS Impact The human immunodeficiency virus, or HIV, is the virus that causes HIV infection. During HIV infection, the virus attacks and destroys the infection-fighting CD4 cells of the body s immune system. Loss of CD4 cells makes it difficult for the immune system to fight infections. Acquired immunodeficiency syndrome, or AIDS, is the most advanced stage of HIV infection (National Institutes of Health, 2012). 1 Despite continued increases in the number of people living with HIV over the past decade, new HIV infections have not increased, indicating that HIV testing, prevention, and treatment programs are effectively reducing the rate of transmission overall (CDC, Fact Sheet, New HIV Infections in the U.S., 2012). Key Takeaways Maryland ranks 19th among the 50 states and territories in total population; however, Maryland was ninth in cumulative number of AIDS cases and fourth in estimated AIDS diagnosis rate (2009). While Maryland has seen a reduction in HIV/AIDS among blacks and whites, and the mortality difference between the groups has been reduced, a large disparity still exists. The incidence rate of HIV infection in Maryland was 11 times higher for blacks and nearly three times higher for Hispanics compared to whites. The incidence rate of AIDS was 13 times higher for blacks and four times higher for Hispanics compared to whites. The HIV prevalence rate for black residents of Dorchester County is approximately 10 times higher than the HIV prevalence rate for white residents. Similarly, the HIV prevalence rate in Wicomico County s black population is approximately 6 times higher than the rate in the white population. HIV/AIDS is more prevalent in Dorchester County than Wicomico County, but both counties experience a far lower HIV/AIDS prevalence rate compared to Maryland. National Data The Centers for Disease Control and Prevention estimates that 1.1 million people in the United States are living with HIV, and nearly one in five of those are not aware that they are infected. Approximately 47,500 people become newly infected with HIV in 2010 (the year for which the most recent data is available). Nearly two thirds of these new infections occurred in gay and bisexual men in Black/African American men and women were also highly affected and were estimated to have an HIV incidence rate that was almost 8 times as high as the incidence rate among whites. In addition to recognized risk behaviors, a range of social and economic factors place some Americans at increased risk for HIV infection. HIV racial disparities are driven by a range of factors that disproportionately affect communities of color. One key factor is the higher HIV prevalence (proportion of people living with HIV) in many African American and Latino communities, which means individuals in those communities face a greater risk of infection with every sexual encounter. Other factors include: stigma and homophobia, which may prevent many from seeking help with HIV prevention; economic barriers and lack of insurance, which can limit access to health care including HIV testing and treatment; higher rates of incarceration among African American men, which may lead to concurrent relationships and 1 National Institutes of Health. AidsInfo

121 fuel the spread of HIV; and higher levels of STDs, which can facilitate HIV transmission, in African American and Latino communities. Prevention efforts have helped keep the rate of new infections stable in recent years, but continued growth in the number of people living with HIV may eventually lead to more new infections if prevention, care, and treatment efforts are not targeted to those at greatest risk (CDC, 2012). 2 State Data By the end of 2009, Maryland had a total of 29,080 reported cases of persons living with HIV and AIDS (see Figure 1). While Maryland ranks 19th among the 50 states and the District of Columbia in total population, in 2009 Maryland was ninth in cumulative number of AIDS cases and fourth among U.S. states and territories in estimated AIDS diagnosis rate (Department of Health and Mental Hygiene, 2009). Figure 1. Number Currently Living with HIV, AIDS, or HIV/AIDS, Maryland, (Source: Maryland HIV/AIDS Epidemiological Profile Fourth Quarter 2010 Data reported through December 31, 2010) 2 Centers for Disease Control and Prevention. Today s HIV/AIDS Epidemic. June

122 From , the Maryland HIV/AIDS mortality rate was reduced by 32 percent among blacks and by 26 percent among whites; the mortality difference between the groups was reduced as well, but a large disparity still exists (see Figure 2). Figure 2. Age-Adjusted HIV/AIDS Mortality Rate, by Race, Maryland (Note: These statistics only represent a portion of the epidemic those cases that have been both confirmed through testing and reported.) The incidence rate of HIV infection was 11 times higher for African Americans and 2.7 times higher for Hispanics compared to whites in Maryland in 2007 (see Figure 3). Figure 3. HIV Incidence Rate, by Race/Ethnicity, Maryland, 2007 (Source: Maryland HIV/AIDS Epidemiological Profile, Fourth Quarter 2008) 122

123 The incidence rate of AIDS was 13 times higher for African Americans and 4 times higher for Hispanics compared to whites in Maryland in 2007 (see Figure 4). Figure 4. AIDS Incidence Rate, by Race/Ethnicity, Maryland, 2007 (Source: Maryland HIV/AIDS Epidemiological Profile, Fourth Quarter 2008) County Data Dorchester County has a higher HIV/AIDS prevalence rate (399 per 100,000 population) than Wicomico County (269.6 per 100,000 population), but both counties have a lower prevalence rate of HIV/AIDS than the state of Maryland (632.9 per 100,000 population) (see Figure 5). 3 HIV Prevalence in Dorchester & Wicomico Counties, Maryland, U.S., Location/Area Total Population Population with HIV / AIDS Prevalence Rate of HIV / AIDS, (Per 100,000 Pop.) Dorchester County, MD 27, Wicomico County, MD 82, Maryland 4,828,037 30, United States 509,288,471 1,733, Figure 5. HIV/AIDS prevalence rate per 100,000 population in Wicomico & Dorchester Counties, MD, & U.S., Community Commons. Community Health Needs Assessment. (2013). Accessed: 123

124 There are significant disparities among the different racial/ethnic groups with regard to HIV infection. The non-hispanic black population of Dorchester County has an HIV prevalence rate of per 100,000 population, which is 10 times higher than the HIV prevalence rate for non-hispanic whites (121.2 per 100,000 population). The Hispanic/Latino population has the second highest HIV prevalence rate in Dorchester County (884 per 100,000 population). Similar disparities are also observed in Wicomico County, with HIV prevalence rates being much higher among the black non-hispanic population ( per 100,000 population), compared to the white non-hispanic population ( per 100,000 population) (see Figures 6 and 7). 3 HIV Prevalence Rate by Race/Ethnicity in Dorchester & Wicomico Counties, Maryland, U.S., Location/Area Non-Hispanic White Non-Hispanic Black Hispanic / Latino Dorchester County, MD , Wicomico County, MD Maryland , United States , Figure 6. HIV prevalence rate by race/ethnicity in Maryland, Wicomico County, Dorchester County, HIV Prevalence Rate by Race/Ethnicity for United States, Maryland, Wicomico County, Dorchester County, Figure 7. HIV Prevalence Rate per 100,000 population by Race/Ethnicity for United States, Maryland, Wicomico County, Dorchester County,

125 From , Wicomico County had an AIDS mortality rate of 6.0 per 100,000 population, which is lower than the state of Maryland s AIDS mortality rate of 8.4 per 100,000 population (Source: NVSS-M). Spotlight on Sexual Transmitted Infections (STI) Chlamydia The incidence rate of Chlamydia trachomatis in Wicomico County decreased from 714 per 100,000 population to per 100,000 population from 2011 to Similarly, the incidence rate for chlamydia also decreased in Dorchester County from per 100,000 population to per 100,000 population during the same time period (see Figure 8). Although the incidence rate of chlamydia improved from 2011 to 2012, it is still worse than the incidence rate of Chlamydia in Maryland. Dorchester County, with a percent higher incidence rate of chlamydia compared to Maryland, is doing far worse than Wicomico County, whose incidence rate is 8.93 pecent higher than Maryland (see Figure 8). Maryland State Health Improvement Process Objective 21, Wicomico and Dorchester County, 2012 Figure 8. Maryland State Health Improvement Process to Reduce Chlamydia trachomatis infections, Wicomico County, Dorchester County, Gonorrhea The incidence of gonorrhea infection is significantly higher in both Dorchester County and Wicomico County compared to the state of Maryland overall. Dorchester County has a gonorrhea incidence rate of per 100,000 population; Wicomico County has a gonorrhea incidence rate of per 100,000 population; and Maryland has a Gonorrhea incidence rate of per 100,000 population (see Figure 9). 3 4 Department of Health and Mental Hygiene. State Health Improvement Process (SHIP) County Health Profiles. (2012). Accessed: 125

126 Gonorrhea Incidence Rate in Dorchester & Wicomico Counties, Maryland, U.S., Location/Area Total Population Total Gonorrhea Infections Gonorrhea Infection Rate (Per 100,000 Pop.) Dorchester County, MD 32, Wicomico County, MD 99, Maryland 5,773,552 6, United States 624,353, , Figure 9. Gonorrhea Incidence Rate per 100,000 population in Dorchester County, Wicomico County, Maryland, & United States, The gonorrhea incidence rate in Wicomico County fluctuated during the time period, from 214 to per 100,000 population. However, improvements in the incidence rates were observed during the last two years of this report; from 2010 to 2011 the Gonorrhea incidence rate decreased by 51 per 100,000 population (see Figure 10). However, the gonorrhea incidence rate in Dorchester County significantly increased from The incidence rate increased from cases to cases per 100,000 population. In 2011 the incidence rate had increased by a total of 134 cases per 100,000 population, which was more than twice the number of cases observed in Compared to Maryland, both Wicomico County and Dorchester County have a significantly higher gonorrhea incidence rate (see Figure 11). Unlike these two counties, Maryland residents statewide have experienced a steady decrease in the incidence rate of gonorrhea from to per 100,000 population, during the time period. 3 Gonorrhea Incidence Rate in Dorchester & Wicomico Counties, Maryland, U.S., Location/ Area Dorchester County, MD Wicomico County, MD Maryland United States Figure 10. Gonorrhea Incidence Rate per 100,000 population, Time Series Data in Dorchester County, Wicomico County, Maryland, & United States,

127 Gonorrhea Incidence Rate Change for United States, Maryland, Wicomico County, Dorchester County, Dorchester County Wicomico County Maryland U.S Figure 11. Gonorrhea Incidence Rate Change for United States, Maryland, Wicomico County, Dorchester County,

128 Local Resources HIV/AIDS Treatment and support for those with HIV or AIDS is provided by both private and public health care providers. Safety net clinics in Wicomico County provide diagnostic services and treatment. Other local services in Wicomico County include: The Wicomico County Health Department offers many services related to HIV/AIDS including: free, confidential and anonymous HIV counseling/testing; HIV partner notification; free HIV/AIDS prevention education; and HIV case management services to eligible residents The HIV Seropositive Clinic provides care and assistance to uninsured residents over the age of 16 with HIV The Ryan White C.A.R.E. act provides financial assistance to eligible residents who need help paying acquiring medications, specialty medical care, food, and transportation The Eastern Region HIV Care Consortium provides outpatient and support services for people that have been diagnosed with HIV The Housing Opportunities for Persons with AIDS (HOPWA) provides financial assistance to cover the costs of rent and utilities for eligible persons with HIV and their families The Dorchester County Health Department also offers a variety of services for individuals infected with HIV including: Confidential and anonymous HIV Antibody testing and Pre/Post HIV test with referral services HIV Medical/Non-Medical Case Management Program links HIV infected individuals to HIV healthcare services such as physician referrals and medical insurance options; educates individuals about other supportive services such as housing programs and financial assistance programs; and provides transportation services to medical appointments for eligible persons The Pharaoh Program is a five-session, culturally sensitive program designed to empower individuals infected with HIV/AIDS and prevent the transmission of HIV/AIDS Prevention with Positives is a four-session individual risk-reduction intervention program to prevent the transmission of HIV/AIDS 128

129 Part b. Population Health 129

130 Chapter 9. Maternal and Infant Health 130

131 b. Population Health Chapter 9. MATERNAL and INFANT HEALTH Impact The relationship between certain maternal behaviors and pregnancy outcomes is well known; chief among these behaviors is the receipt of early and appropriate prenatal care. Prenatal care should begin in the first trimester of pregnancy, or, preferably, prior to conception. This is especially important for minority women, as they experience higher rates of infant mortality and are also more likely to deliver low birth weight babies. Babies born prematurely are at a higher risk of death because they are likely to be underdeveloped and more susceptible to lifethreatening infections, respiratory distress syndrome, cerebral palsy, and learning and developmental disabilities (NICHHD, 2012). According to the Centers for Disease Control and Prevention, low birth weight is the single most important factor correlating with infant morbidity (CDC, Pediatric and Pregnancy Nutrition Surveillance System, 2009). Babies born weighing less than 2,500 grams (5.5 lbs.) who survive are at a higher risk for serious health problems than those infants who are born at healthy weights. Infant mortality is defined as the rate at which babies die before 12 months of age, and is one of the most serious public health issues in the United States. It serves as an excellent indicator of the effectiveness of a country's health care system, as it is directly related to the quality and availability of health care and maternal health (Infant Mortality, CDC, 1997). One of the specific objectives of Healthy People 2020 is to decrease the number of infant deaths to fewer than 6.0 per 1,000 live births among all racial and ethnic groups (Healthy People, 2020). Key Takeaways Across Maryland, rates of prenatal care are going down and rates of low birth weight are going up, but infant mortality continues to decrease as medical advances make it possible to save more at-risk babies. Although infant mortality is generally decreasing, blacks continue to experience the highest rates of infant mortality in the state. The adolescent birth rate among Hispanics is approximately double the pregnancy rate of other adolescent populations across the state. Both Wicomico County and Dorchester County residents had teenage pregnancy rates that were higher than Maryland s rate in White expectant mothers in Wicomico County were more likely to receive early prenatal care than black and Hispanic expectant mothers. In both Wicomico County and Dorchester County, infant mortality rates have been on the decline; however, they are still higher than Maryland s infant mortality rate. 131

132 National Data Receipt of Prenatal Care: In the United States (2007), 70.8 percent of women who gave birth received prenatal care within the first three months of their pregnancies, while 7.1 percent either did not receive care until the last three months of their pregnancies or did not receive prenatal care at all (National Vital Statistics Reports, 2010). Low Birth Weight: Nationally, 8.2 percent of all babies were born with a low birth weight and 12.2 percent were born preterm in 2009 (National Vital Statistics Reports, 2011). Infant Mortality: Despite advanced medical knowledge and technology, infant mortality continues to persist as a problem for minority populations in the United States. This is a particular concern for blacks across the country, as well as in Maryland, as the infant mortality rate in this group is significantly higher than for any other racial or ethnic group. Nationally, the infant mortality rate among black infants is 13.3 deaths per 1,000 live births, which is more than double the rate among whites at 5.6 deaths per 1,000 live births (U.S. Census Bureau, Current Population Survey, 2011). State Data Birth Rates: In 2009, there were 77,974 live births in Maryland, up from 74,880 in 2005 (MD Vital Statistics Administration, Annual Report, 2009). The birth rate for Hispanic mothers was the highest for all of Maryland compared to non-hispanic white and non-hispanic black mothers. The birth rate for Hispanic mothers in the state grew by over 40 percent between 2005 and During this same time period, the birth rate among white mothers in Maryland decreased 11 percent and remained the same for black women. Hispanic women have the highest birth rate in Maryland, with 9.9 percent of women between the ages of 15 to 50 giving birth, compared to 5.9 percent for all women, 5.3 percent for white women, and 6.1 percent for black women. 1 Teenage mothers are at greater risk for having preterm and low birth weight babies, and are also therefore at greater risk of babies with infant mortality (Department of Health & Human Services, Preventing Infant Mortality, 2006). In 2009, the birth rate among girls of all races between the ages of 15 and 19 in Maryland was 31.2 per 1,000 females. The adolescent Hispanic birth rate, however, was just over double that figure, at 66.4 (MD VSA, Annual Report, 2009). In 2010, the teen pregnancy rate for Maryland was lower than the national average at 27.2 teen births for every 1000 females ages Of the 6,223 pregnant teenage mothers in the state in 2010, 53.1 percent were black, 21.3 percent were white, 16.6 percent were Hispanic, and 1.1 percent were Asian or American Indian (Maryland Adolescent Reproductive Health Facts, Office of Adolescent Health, 2010). Receipt of Prenatal Care: In Maryland, 6.3 percent of pregnant women of all races received late or no prenatal care in 2010 (MD Vital Statistics, Annual Report, 2010). That percentage varied greatly among different racial/ethnic groups: 4.0 percent among whites, 5.9 percent among Asians or Pacific Islanders, 8.9 percent among Hispanics, 9.5 percent among American Indians, and 10.9 percent among blacks. Over the last 10 years, the percent of pregnant women receiving 1 Department of Legislative Services, Office of Policy Analysis. Overview of Hispanic Community in Maryland Accessed 2013: Community.pdf 132

133 late or no prenatal care has increased across the board in Maryland, indicating that rates of appropriate prenatal care are declining (see Figure 1). Figure 1. Percent of Births to Women Receiving Late or No Prenatal Care by Race, Maryland, Note: The methodology for collecting information on the time during pregnancy that prenatal care began was changed in the 2010 revision of the Maryland birth certificate. As a result, prenatal care data collected in 2010 are not comparable to data collected in earlier years. For this reason, the trend data in Figure 1 does not include data from Low Birth Weight: Compared to the nation, Maryland had a higher percentage of low birth weight babies at 8.8 percent in 2010 (MD Vital Statistics, Annual Report, 2010). The percent of babies born with low birth weight increased very slightly among all racial groups in Maryland between 2000 and 2009, potentially due to the fact that rates of early prenatal care are decreasing (see Figure 2). Black mothers delivered low birth weight babies almost twice as often as white mothers in Figure 2. Low Birth Weight Births by Race, Maryland,

134 Infant Mortality: In 2010, Maryland had an overall infant mortality rate of 6.7 deaths per 1000 live births for all races, and the infant mortality rate among blacks is significantly higher than for any other racial/ethnic group. The leading cause of infant mortality is low birth weight and preterm births, followed by congenital anomalies, Sudden Infant Death Syndrome and maternal complications (MD Department of Health & Mental Hygiene, 2011). Despite the fact that more women are going without prenatal care, the infant mortality rate in Maryland overall and for white mothers decreased slightly from (see Figure 3). Figure 3. Infant Mortality Rate by Race, Maryland, Breastfeeding: Breastfeeding is advantageous to both the mother and baby, and is also addressed in Healthy People For babies, breastfeeding has many benefits including being extremely nutritious and boosting their immune systems. Breastfed babies may be at a lower risk for Sudden Infant Death Syndrome, Type 1 diabetes, childhood leukemia, and atopic dermatitis. Mothers can also benefit from breastfeeding by lowering the risk of developing Type 2 Diabetes, postpartum depression, ovarian cancer, and breast cancer (Breastfeeding, Office on Women s Health, 2011). In 2007, 73 percent of mothers in Maryland had ever breastfed, compared to 75 percent of mothers in the United States. The World Health Organization recommends that women exclusively breastfeed for the first six months after birth, but only 45.5 percent of mothers in Maryland were breastfeeding after six months (National Immunization Survey, 2007). 134

135 County Data Wicomico County Birth Rates: In 2011, Wicomico County had a relatively high teen pregnancy rate at 33.3 live births per 1,000 females ages This rate is higher than the state rate at 33 live births per 1,000 females ages The teen birth rate is significantly higher among Hispanics compared to other racial/ethnic groups at 80.0 live births per 1,000 females ages (see Figure 4). Figure 4. Teen Birth Rate by Race/Ethnicity in Wicomico County, At a rate of 33.3 live births per 1,000 females ages 15-19, Wicomico County does not meet the Maryland SHIP target of 29.6 live births per 1,000 females ages (see Figure 5). Wicomico County Teen Birth Rate & Maryland SHIP Target Teen Birth Rate, 2011 Figure 5. Wicomico County Teen Birth Rate & Maryland SHIP Target Teen Birth Rate, County Health Rankings & Roadmaps. Health Outcomes Wicomico County. (2013). Accessed: 3 Peninsula Regional Medical Center. Creating Healthy Communities Community Dashboard. Wicomico County. (2011). Accessed: 135

136 Receipt of Prenatal Care: Compared to babies of mothers who receive prenatal care, babies of mothers that do not are three times more likely to have a low birth weight and five times more likely to die. 3 The prevalence of infant mortality can be reduced by increasing access to prenatal care, especially during the first trimester of pregnancy. In Wicomico County, white women are most likely to receive prenatal care during the first trimester (78.6 percent) compared to other racial and ethnic groups. Within minority groups, Asian women are most likely to receive prenatal care during the first trimester at 72.7 percent, and Hispanics were the least likely to receive early prenatal care at 61.2 percent (see Figure 6). Figure 6. Percent of Mothers who Received Early Prenatal Care by Race/Ethnicity, Wicomico County, In addition, mothers in the age range gave birth to the highest percentage of babies with low birth weight compared to any other maternal age group (see Figure 7). Figure 7. Percent of Mothers who gave birth to Babies with Low Birth Weight by Maternal Age, Wicomico County, Overall, 72.7 percent of mothers who gave birth received early prenatal care in Wicomico County. This percentage did not meet the Healthy People 2020 target of 77.9 percent or the Maryland State Health Improvement Process 2014 target of 84.2 percent

137 Low Birth Weight: When analyzed by race, significant disparities in low birth weight become evident between non-hispanic blacks and non-hispanic whites. In Wicomico County, non- Hispanic blacks had significantly higher rates of low birth weight births than non-hispanic whites in In Wicomico County, 13.4 percent of non-hispanic black mothers had low birth weight babies compared to 7.7 percent of non-hispanic white mothers (see Figure 7). Figure 7. Babies with Low Birth Weight by Maternal Race/Ethnicity, Wicomico County, In 2011, Wicomico County had 9.0 percent of births in which the newborn weighed less than 2,500 grams (5 pounds, 8 ounces) (see Figure 7). This percentage is higher than the Healthy People 2020 target of 7.8 percent, and the Maryland State Health Improvement Process 2014 target of 8.5 percent 3. Infant Mortality: Wicomico County had a relatively high infant mortality rate for infants within the first year of life at 7.5 deaths per 1,000 live births in the total population (see Figure 8). Although the rate of infant mortality in Wicomico County has decreased over time from , it is much higher than the 2014 Maryland State Health Improvement Process target rate of 6.6 deaths per 1,000 live births (see Figure 8). It also does not meet the Healthy People 2020 target of 6.0 deaths per 1,000 live births 3. Infant Mortality Rate in Wicomico County, Figure 8. Infant Mortality Rate per 1,000 Live Births, Wicomico County,

138 Dorchester County Birth Rates: According to the Maryland State Health Improvement Process (SHIP), the rate of births to mothers ages years in Dorchester County was at a high 66.9 live births per 1,000 teenage female population in This rate is significantly higher than Maryland s SHIP rate of 27.2 live births per 1,000 teenage female population in 2012 (see Figure 9). The 2014 Maryland SHIP target is to reduce Dorchester County s rate of 66.9 to 29.6 live births per 1,000 teenage female population. In Dorchester County, black residents had twice the rate of births to mothers aged at 94.8 per 1,000 teenage female population compared to non-hispanic white residents at 46.2 per 1,000 teenage females (see Figure 9). Maryland State Health Improvement Process, Dorchester County, 2012 Figure 9. Maryland State Health Improvement Process Objectives, Dorchester County, Low Birth Weight: As illustrated in Figure 9, in Dorchester County 11.3 percent of mothers had low birth weight babies compared to 8.8 percent of mothers in Maryland. One of the Maryland SHIP objectives for Dorchester County is to reduce low birth weight births from 11.3 percent to 8.5 percent by Regarding racial/ethnic groups, black residents from Dorchester County had a higher rate of low birth weight babies at 16.1 percent, compared to 8.3 percent among non- Hispanic white residents. Infant Mortality: One of the Maryland State Health Improvement Process objectives for 2014 is to reduce infant deaths to a targeted rate of 6.6 infant deaths per 1,000 live births. In 2012, Dorchester County had a rate of 16.9 infant deaths per 1,000 live births. Although there has been a slight decrease of infant deaths from 18.8 per 1,000 live births in 2011, it is still much higher than the Maryland rate of 6.7 deaths per 1,000 live births (see Figure 9). 4 Maryland Department of Health and Human Services. Maryland State Health Improvement Process. Dorchester County. (2012). Accessed: 138

139 Local Resources Maternal and Child Health There are numerous services offered to mothers and their children through the following federal, state, and local programs: Women, Infants, & Children (WIC) is a federal program that provides low-income women and children through the age of 5 years old who are nutritionally at-risk with food and nutrition services. Maryland s Children s Health Program provides full health coverage to low-income pregnant women and children through the age of 19 years old. Medical Assistance for Families program provides full health benefits to adults who are parents or guardians of dependent children. Must meet technical and financial requirements to be eligible. Memorial Hospital at Easton has the Shore Health System s Birthing Center, which provides educational programs on Labor and Delivery, New Mom New Baby & Infant Safety, Breastfeeding, Big Brother & Big Sister, and Infant CPR. Peninsula Regional Medical Center offers education/wellness classes, women s health services, and in-vitro fertilization services. Special Treasures Are Remembered (STAR) is a program at Peninsula Regional Medical Center to support and assist women who have suffered the loss of an infant during or after pregnancy. Wicomico County Health Department s Family Planning Program provides gynecological examination, contraception, and vasectomy counseling. Free services include pregnancy testing, contraceptive counseling, and condoms. Children s Medical Services (CMS) program provides financial assistance for families to acquire special medical and rehabilitative care for children with chronic illnesses or disabilities of growth and development. Babies Born Healthy Program provides free services through the WIC program including multivitamins, pregnancy testing, and nurse assessment on contraception and family planning. May need to meet eligibility requirements. Dorchester County Health Department offers maternal and child health services including: Family Planning program that provides services for women including contraceptive counseling, pregnancy testing, and gynecological care to women of childbearing age; The Child Health Program provides home visitations, case management services, and immunization services May need a referral from a private provider. 139

140 Chapter 10. Senior Health 140

141 Chapter 10. SENIOR HEALTH Impact During an individual s lifespan, many body functions naturally begin to decline. The changes are results of a combination of factors, including genes, lifestyle and disease. 1 Normal aging brings about the following changes: Eyesight - loss of peripheral vision and decreased ability to judge depth. Decreased clarity of colors (for example, pastels and blues). Hearing - loss of hearing acuity, especially sounds at the higher end of the spectrum. Also, decreased ability to distinguish sounds when there is background noise. Taste - decreased taste buds and saliva. Touch and Smell - decreased sensitivity to touch and ability to smell. Arteries - stiffen with age. Additionally, fatty deposits build up in one s blood vessels over time, eventually causing arteriosclerosis (hardening of the arteries). Bladder - increased frequency in urination. Body Fat - increases until middle age, stabilizes until later in life, then decreases. Distribution of fat shifts - moving from just beneath the skin to surround deeper organs. Bones - somewhere around age 35, bones lose minerals faster than they are replaced. Brain - loses some of the structures that connect nerve cells, and the function of the cells themselves is diminished. Heart - is a muscle that thickens with age. Maximum pumping rate and the body's ability to extract oxygen from the blood both diminish with age. Kidneys - shrink and become less efficient. Lungs - somewhere around age 20, lung tissue begins to lose its elasticity, and rib cage muscles shrink progressively. Maximum breathing capacity diminishes with each decade of life. Metabolism - medicines and alcohol are not processed as quickly. Prescription medication requires adjustment. Reflexes are also slowed while driving, therefore an individual might want to lengthen the distance between oneself and the car in front and drive more cautiously. Muscles - muscle mass declines, especially with lack of exercise. Skin - nails grow more slowly. Skin is more dry and wrinkled. It also heals more slowly. Sexual Health - women go through menopause, vaginal lubrication decreases and sexual tissues atrophy. In men, sperm production decreases and the prostate enlarges. Hormone levels decrease. 1 Area Agency on Aging. What is Normal Aging? Accessed

142 Key Takeaways The percent of Maryland residents over the age of 60 is expected to increase from 15 percent of the population in 2010 to 25 percent by Although most seniors prefer to receive long-term care at home, almost 90 percent of Maryland Medicaid s long-term care funds are spent on institutional care. In Wicomico County, 9.1 percent of seniors live below the poverty level, with higher percentages among minority and women seniors. The number of seniors with health problems appears to increase as income decreases. National Data Demographics: The older U.S. population (age 65+) numbered 40.4 million in 2010, an increase of 5.4 million or 15.3 percent since They represented 13.1 percent of the U.S. population, which equates to over one in every eight Americans (see Figure 1). Figure 1. Persons Age 65+ as a Percentage of Total Population, United States, 2010 By 2030, it is estimated that there will be about 72.1 million seniors (19 percent of the total population), which is more than twice their number in 2000 (see Figure 2) (DHHS, Administration on Aging, Profile 2011). 142

143 Figure 2. Number of Persons Age 65+ (in millions), United States, (Note: Increments in years are uneven. Source: DHHS, Administration on Aging, accessed According to the U.S. DHHS Administration on Aging s report, A Profile of Older Americans: 2011, the number of Americans aged who will reach 65 over the next two decades increased by 31 percent during the last decade ( ). Minority populations have increased from 5.7 million in 2000 (16.3 percent of the elderly population) to 8.1 million in 2010 (20 percent of the elderly) and are projected to increase to 13.1 million in 2020 (24 percent of the elderly). In 2010, 20 percent of persons age 65+ in the United States were minorities: 8.4 percent were African American, 6.9 percent were persons of Hispanic origin (any race), about 3.5 percent were Asian or Pacific Islander, and less than 1 percent were American Indian or Native Alaskan. In addition, 0.8 percent of persons age 65+ identified themselves as being of two or more races (DHHS, Administration on Aging, Profile 2011). Persons reaching age 65 have an average life expectancy of an additional 18.8 years (20.0 years for females and 17.3 years for males). Older women outnumber older men in the U.S. at 23.0 million older women to 17.5 million older men. Older men were much more likely to be married (72 percent) than older women (42 percent), and 40 percent of older women were widows in 2010 (see Figure 3). 143

144 Figure 3. Marital Status of Persons Age 65+, United States, 2010 (Source: DHHS, Administration on Aging, 2011) Over half (55.1 percent) of older non-institutionalized persons lived with their spouse in 2010, but the proportion living with their spouse decreased with age, especially for women (see Figure 4). About 29 percent (11.3 million) of non-institutionalized older persons live alone (8.1 million women, 3.2 million men). Almost half of older women (47 percent) age 75+ live alone. Additionally, about 485,000 grandparents aged 65+ had the primary responsibility for their grandchildren who lived with them. Living Arrangements of Persons 65+, 2010 Figure 4. Living Arrangements of Persons Age 65+, United States, 2010 (Source: DHHS, Administration on Aging, 2011; based on data from U.S. Census Bureau 2010 Current Population Survey) 144

145 Income & Poverty: The median income of older persons in 2010 was $18,819: $25,704 for males and $15,072 for females (see Figure 5). Households containing families headed by persons 65+ reported a median income in 2010 of $45,763. The major sources of income as reported by seniors in 2009 were Social Security (reported by 87 percent of seniors), income from assets (reported by 53 percent), private pensions (reported by 28 percent), government employee pensions (reported by 14 percent), and earnings (reported by 26 percent). Social Security constituted 90 percent or more of the income received by 35 percent of beneficiaries in 2009 (22 percent of married couples and 43 percent of nonmarried beneficiaries). Figure 5. Living Arrangements of Persons Age 65+, United States, 2010 (Source: DHHS, Administration on Aging, 2011) Almost 3.5 million elderly persons (9.0 percent) were below the poverty level in During 2011, the U.S. Census Bureau also released a new Supplemental Poverty Measure (SPM) which takes into account regional variations in the livings costs, non-cash benefits received, and non-discretionary expenditures but does not replace the official poverty measure. The SPM shows a poverty level for older persons of 15.9 percent (DHHS, Administration on Aging, Profile 2011). Health: Elderly people are healthier today than they were 30 years ago. From , 40 percent of non-institutionalized seniors assessed their health as excellent or very good (compared to 64.7 percent of persons aged years). There were differences among racial/ethnic groups on this measure, with older African Americans (26.0 percent), older American Indians/Alaska Natives (24.3 percent) and older Hispanics (28.2 percent) less likely to rate their health as excellent or very good than were older whites (42.8 percent) or older Asians (35.3 percent). Most seniors have at least one chronic condition and many 145

146 have multiple conditions. In , the most frequently occurring conditions among seniors were: uncontrolled hypertension (34 percent), diagnosed arthritis (50 percent), all types of heart disease (32 percent), any cancer (23 percent), diabetes (19 percent), and sinusitis (14 percent) (DHHS, Administration on Aging, Profile 2011). Almost 63 percent of U.S. seniors reported in 2010 that they received an influenza vaccination during the past 12 months and 59 percent reported that they had ever received a pneumococcal vaccination. About 27.7 percent (of persons 60+) reported height/weight combinations that categorize them as obese. Almost 35 percent of persons aged and 24 percent of persons 75+ reported that they engage in regular leisure-time physical activity. Only 9.5 percent reported that they are current smokers and only 5 percent reported excessive alcohol consumption. Furthermore, only 2 percent reported that they had experienced psychological distress during the past 30 days (DHHS, Administration on Aging, Profile 2011). Mental Health: It can be difficult for health care workers, families and seniors themselves to distinguish between problems related to aging and those linked to mental illness. Depression is considered the most common mental disorder of people aged 65 and older. The symptoms of depression often appear in people who have other conditions, or can mimic the symptoms of dementia; its victims withdraw, cannot concentrate, and appear confused. Some experts estimate that as many as 10 percent of those diagnosed with dementia actually suffer from depression that, if treated, is reversible. Dementia (characterized by confusion, memory loss, and disorientation) is not an inevitable part of growing old. In fact, only about 10 percent of Americans aged 65 and older suffer from this condition. Of that number, an estimated 60 percent suffer from Alzheimer s disease, a type of dementia for which no cause or cure has been found. Alzheimer s disease, which causes some of the brain s cells to die, involves a part of the brain that controls memory. As it spreads to other parts of the brain, the illness affects a greater number of intellectual, emotional, and behavioral abilities. An adult s chances of developing the illness are one in 100, but the incidence increases with age. One million people older than 65 are severely afflicted with Alzheimer s disease and another two million are in the moderate stages of the disease. Seniors take many more medications than other age groups. Coupled with a slower metabolism, these substances can stay in the body longer and quickly reach toxic levels. Moreover, because many older people take more than one medication and may drink alcoholic beverages, there is a high risk that drugs will interact, causing confusion, mood changes, and other symptoms of dementia. 2 Health Care: In 2007, the rate of discharge from short hospital stays by seniors (3,395 per 10,000 persons aged 65+) was about three times the comparable rate for persons of all ages (1,149 per 10,000 persons). The average length of stay for persons aged 65+ was 5.6 days compared to 4.8 days for persons of all ages. Seniors also averaged more office visits with doctors in 2007 (7.1 visits for those 65+ versus 3.7 visits for persons 45-65). In 2010, older consumers averaged out-of-pocket health care expenditures of $4,843, an increase of 49 percent since In contrast, the total population spent considerably less, 2 American Psychiatric Association. Seniors: Types of Mental Disorders. Accessed

147 averaging $3,157 in out-of-pocket costs. Older Americans spent 13.2 percent of their total expenditures on health, which is more than twice the proportion spent by all consumers (6.6 percent) (NCHS and Bureau of Labor Statistics, accessed via DHHS, Administration on Aging, Profile 2011) Health Insurance Coverage: In 2010, almost all (93.1 percent) of non-institutionalized persons age 65+ were covered by Medicare. Medicare covers mostly acute care services and requires beneficiaries to pay part of the cost, leaving about half of health spending to be covered by other sources. About 86 percent of non-institutionalized Medicare beneficiaries in 2009 had some type of supplementary coverage (see Figure 6). Figure 6. Health Insurance Coverage of Persons Age 65+, United States, 2010 (Source: DHHS, Administration on Aging, Note: Data is for the non-institutionalized elderly. A person can be represented in more than one category) Disability/Activity Limitations: Some type of disability (i.e., difficulty in hearing, vision, cognition, ambulation, self-care, or independent living) was reported by 37 percent of seniors in Some of these disabilities may be relatively minor but others cause people to require assistance to meet important personal needs. Reported disability increases with age: 56 percent of persons over 80 reported a severe disability and 29 percent of the age 80+ population reported that they needed assistance. Presence of a severe disability is also associated with lower income levels and educational attainment (DHHS, Administration on Aging, Profile 2011). In a study that focused on the ability to perform specific activities of daily living (ADLs), over 27 percent of community-resident Medicare beneficiaries over age 65 in 2009 had difficulty in performing one or more ADLs, and an additional 12.7 percent reported difficulties with instrumental activities of daily living (IADLs) (see Figure 7). 147

148 Figure 7. Percent of Persons with Limitations in Activities of Daily Living, by Age, United States, 2010 (Note: the figures above are taken from surveys of the non-institutionalized elderly. Sources: Americans with Disabilities: 2005, December 2008, P and other Internet releases of data from the U.S. Census Bureau, the Centers for Medicare and Medicaid, and the National Center on Health Statistics, including the NCHS Health Data Interactive data warehouse; accessed 2013 via DHHS, Administration on Aging, Profile 2011.) By contrast, 95 percent of institutionalized Medicare beneficiaries had difficulties with one or more ADLs and 74 percent of them had difficulty with three or more ADLs. Although nursing homes are being increasingly used for short-stay post-acute care, about 1.3 million elderly are in nursing homes (about half are age 85 and over). These individuals often have high needs for care with their ADLs and/or have severe cognitive impairment due to Alzheimer's disease or other dementias. Almost all community resident seniors with chronic disabilities (over 90 percent) receive either informal care (from family or friends) or formal care (from service provider agencies) (National Long Term Care Survey, 1999). 148

149 State Data The number of older Marylanders is increasing, according to the Maryland Department of Aging. Of the 5.3 million people in Maryland in 2010, 15 percent (801,036) were over the age of 60. The percentage is expected to increase to 25 percent of Maryland's projected population of 6.7 million by the year Additionally, the number of older seniors over the age of 85 continues to grow rapidly. This cohort is projected to grow in number, statewide, from 98,126 in 2010 to 164,695 by the year Marylanders aged 60 and over, with functional disabilities related to mobility or personal care, who are living in the community, accounted for 237,004 persons, over 19 percent of the total number of elderly Marylanders, in In 2000, 63,978 older Marylanders lived in poverty as defined by the federal poverty guidelines. Of Maryland s age 60+ minority population in 2000, 15.7 percent lived in Montgomery County (MD Department of Aging). According to the American Association of Retired Persons (AARP), most seniors (89 percent) prefer to receive long-term care at home; however, almost 90 percent of Maryland s Medicaid funds that are spent on long-term care for older people and adults with disabilities pays for institutional care (i.e., nursing home care). In addition to the 11 percent that Maryland Medicaid spends on in-home care, 600,000 Marylanders are providing family care-giving to a loved one at home, which is valued at $6.6 billion. 4 In 2007, Maryland s nursing homes had an occupancy rate of 87 percent. This care is expensive; the average nursing home private pay rate was $221 per day in 2008, which was the 13 th highest rate in the nation. Maryland s average private pay rate for home health aides ($19 per hour) was right at the national average; its rate for Medicarecertified aides ($29 per hour) was lower than the national average; and its rates for adult day care ($69 per day) were higher than the national average in 2008 (AARP). One in seven Maryland residents, and 86 percent of Maryland residents age 65 or older, received social security in Social Security makes up 50 percent or more of the income for half of Marylanders age 65+ and a quarter of Maryland seniors rely on Social Security as their only source of income. 5 3 U.S. Census, 2000; MD Department of Planning, Population Projections - revised 9/2005. Accessed via Maryland Department of Aging Gibson, Mary Jo; Fox-Grage, Wendy; Houser, Ari. Across the States 2009: Profiles of Long-Term Care and Independent Living: Executive Summary, State Data, and Rankings. AARP Policy Institute. Accessed AARP. Social Security: 2012 Maryland Quick Facts. Accessed Maryland-Quick-Facts-AARP.pdf 149

150 County Data Wicomico County In Wicomico County, percent of the population was 65 years of age or older in 2011, which is similar to the Maryland population of residents 65 years or older (12.11 percent). According to the U.S. Census, percent of the male population is 65 years or older, and percent of the female population is 65 years or older. Additionally, percent of whites, 9.42 percent of Blacks or African Americans, 2.08 percent of Native Americans/Alaskan Natives, 5.04 percent of Asians, percent of Non- Hispanic/Latinos, and 4.44 percent of Hispanic/Latino are 65 or older (U.S. Census Bureau, A Compass for Understanding and Using American Community Survey Data, 2008). In Wicomico County, adults age 65 years of age or older have the highest percentage of diabetes in the county. Wicomico residents who are 65 years or older account for 26 percent of the total population who suffer from diabetes (BRFSS 2011); Wicomico residents who are between the ages of 45 and 65 account for 10.9 percent of the population suffering from diabetes. Lastly, Wicomico residents between the ages of 18 to 44 account for only 1.6 percent of individuals suffering from diabetes in the county (see Figure 8). Figure 8. Adults with Diabetes by Age in Wicomico County, Peninsula Regional Medical Center. Creating Health Communities. Community Dashboard Wicomico County. (2013). Accessed: 150

151 According to the Community Dashboard, 9.1 percent of Wicomico County seniors age 65 or older were living below the poverty level from Figure 9 shows the distribution within the county of people 65+ living below the poverty level from People 65+ Living Below Poverty Level in Wicomico County, Figure 9. Wicomico County People 65+ Living Below Poverty Level, Time Series Data, A higher percentage of minority seniors age 65+ live below the poverty level in Wicomico County (18.4 percent black/african American and 7.9 percent Hispanic/Latino) compared to non-hispanic white seniors (7.5 percent) (see Figure 10). Figure 10. People 65+ Living Below Poverty Level, by Race/Ethnicity, Wicomico County

152 Women age 65 and above comprise 11.4 percent of the population living below poverty level in Wicomico County, compared to 6.0 percent of men (see Figure 11). Figure 11. People 65+ Living Below Poverty Level, by Gender, Wicomico County Dorchester County Dorchester County has a senior population (age 65 years and above) of 5,648 individuals, which accounts for percent of the total county population. Compared to the state of Maryland (12.11 percent 65 years old and above), Dorchester County has a higher percentage of senior residents age 65 years or more. Census data shows that percent of males and percent of females living in Dorchester County are 65 years or older. Additionally, percent of whites, percent of blacks/african Americans, percent of Native Americans/Alaskan Natives, 4.64 percent of Asians, and 2.91 percent Hispanic are 65 years or older (see Figure 12) (U.S. Census Bureau, A Compass for Understanding and Using American Community Survey Data, 2008) Dorchester County Maryland U.S. 0 White Black Native Amercian Asian Hispanic Figure 12. Residents Age 65+ by Race and Ethnicity in Dorchester County, MD, U.S., Community Commons. Community Health Needs Assessment. Dorchester County. (2013). Accessed: 152

153 From , the senior population living in poverty in Dorchester County was 1.2 percent higher than the senior population living in poverty in the state of Maryland (see Figure 13). Figure 13. Residents Age 65+ living in poverty in the United States, Maryland and Dorchester County, (Source: U.S. Census Bureau) No other significant data were found regarding the health of senior residents in Dorchester County, Maryland. 153

154 Local Resources Senior Health Local agencies within Dorchester and Wicomico counties provide a comprehensive range of services that focus on the health and wellbeing of senior citizens. Delmarva Community Services, Inc. provides programs for senior citizens in Dorchester County. Program services include health education, housing, advocacy services, in-home services, and nutrition. Pleasant Day Medical Adult Day Care is operated by the Dorchester County Commission on the Aging, Inc. Pleasant Day provides nursing care to seniors, with chronic health conditions, to allow them to live as independently as possible within their homes. Maintaining Active Citizens (MAC) is the designated area agency on aging for several counties on the Eastern Shore including Dorchester and Wicomico counties. The agency provides services and programs for senior citizens such as: Meals-on-Wheels, a program that assists seniors who cannot cook or do not have transportation by delivering meals to their homes; Housing services offers comprehensive care at senior centers with preventive healthcare services, nutrition services, fitness programs, employment counseling, etc. Additionally, the Senior Assisted Group Home Subsidy Program provides low-to-moderate income senior citizens with access to assisted living in small group homes. Services include meals, personal care, and 24-hour supervision; The Richard A. Henson Wellness Center provides a range of programs and services specifically for the elderly population. At the Center, seniors can participate in fitness classes from Tai Chi to Zumba. Other services include wellness classes, health education, health screenings, and Alzheimer s support; MAC Senior Support Services promotes the advocacy of senior rights through programs such as the Senior Information & Assistance Program, Long Term Care Advocacy, Senior Health Insurance Counseling Program, Legal Services, and Tax Aid Program. 154

155 Part c. Social Determinants of Health 155

156 c. Social Determinants of Health Social determinants of health conditions in which people are born, grow, live, work, and age not only influence exposures to risk factors and health disparities, but also opportunities to live healthy lives with access to appropriate health resources. As social determinants play an essential role in health disparities, health interventions are salient and sustainable when they address the root causes of the disparities. Despite recognition that multiple factors outside of the medical system contribute directly to the health of individuals and communities, they are often left unaddressed in interventions to improve health status, access to care, and outcomes. Addressing these factors requires collaboration among public officials, researchers, community organizations, and members in public health, health care, and other relevant domains. We often think of health as something driven by one s genetics and behaviors something that is treated in a doctor s office or hospital. In truth, health status is a product of many interrelated factors, including environmental, behavioral, and socioeconomic conditions. Social circumstances, such as the availability of safe housing and nutritious food, as well as access to educational and employment opportunities, are strongly associated with good health. They affect people s basic ability to make healthy choices. Negative social determinants can impact people s health in two critical ways: (1) by harming actual health status, and (2) by creating barriers to accessing health care and achieving better health. For example, a person may live in a neighborhood where it is challenging to practice healthy behaviors, such as exercising and eating healthy foods, due to a lack of local resources (e.g., grocery stores and community parks). As a result, this person may struggle with weight or suffer from chronic health conditions. In addition, where a person lives, and his/her financial resources, may limit his/her access to transportation to get to a doctor s appointment. This report considers four key determinants, based on existing research and our interviews with local organizations. Factors such as income and race/ethnicity play a critical role in each determinant, as minority and low-income populations are more likely to experience disadvantages in multiple areas. 156

157 Chapter 11. Food Access 157

158 Chapter 11. FOOD ACCESS Poverty often leads to food insecurity the limited availability of nutritious food. As a result, low-income families are disproportionately overweight and undernourished. Such conditions are the precursors to a range of other health conditions, including diabetes, heart disease, and hypertension. Food insecurity is also tied to lower self-reported health status and depression. Historically, malnutrition has been understood as a state of under-nutrition; however, this meaning is changing. Recent literature now defines malnutrition as a state of improper nutrition either too little food or too much unhealthy food. The United States Department of Agriculture s (USDA) definition of food insecurity is the limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways. 1 Within communities where there is food insecurity, the problem is often not that there are too few calories to feed people in the community. It is more often that the calories available are nutritionally deficient. While people may not be hungry, they are still undernourished. As a result, places with high food insecurity are often correlated with obesity. When households have limited money for food, families compromise the quality of their diets, eating more energy-dense foods that are lower in nutrients. Energy-dense foods (higher in fats and carbohydrates) cost less than nutrient-dense foods. Food insecurity impacts populations differently. In an examination of their data for 2008, the USDA found that very low food security (a more intense level of insecurity) varied by race, ethnicity, income, and head of household (see Figure 1). 2 Figure 1. Food Insecurity by Household Demographics, United States, Anderson, S. Core Indicators of Nutritional State for Difficult-to-Sample Populations. The Journal of Nutrition Nord, M. et al. Household Food Security in the United States, Economic Research Service, United States Department of Agriculture. November

159 Federal programs aim to address the issue of food insecurity in this country, including USDA-sponsored Supplemental Nutrition Assistance Program (SNAP); School Meals; Women, Infants, and Children (WIC); Summer Food Service Program; and Child and Adult Care Food Program. A recent USDA study of the SNAP program indicated that that a 10 percent rise in spending on food led to an increase in overall diet quality, as measured by a comparison to the most recent federal dietary guidelines. 3 The SNAP program also has a nutritional education component. This includes education about food shopping and food resource management. In evaluations of this portion of the nutrition education program, one study found that among program participants, improved food shopping practices correlated with increased consumption of nutrients. The effects of food insecurity are not limited to obesity. Food insecurity also can impact other aspects of physical and mental health. One recent study examined the role of food insecurity on health between African American and white women who were recipients of Temporary Assistance for Needy Families (TANF). This study found that persistent or recurrent food insecurity is a significant and independent predictor of self-rated health status in this population. Food insecurity was also found to correlate with certain screening criteria for major depression. 4 3 Mabli, J. et al. Food Expenditures and Diet Quality among Low-Income Households and Individuals. Mathematica for the United States Department of Agriculture. November Siefert, K. et al. Food Insufficiency and Physical and Mental Health in a Longitudinal Survey of Welfare Recipients. Journal of Health and Social Behavior. June

160 County Data In Wicomico County, 70 percent of the adult population consumes five servings of fruits and vegetables daily. This proportion is slightly lower than Maryland s average of 72.1 percent 5. Wicomico County adults who eat fruits and vegetables are fairly evenly distributed among different age groups. However, Wicomico County residents ages eat slightly more fruits and vegetables compared to other age groups (see Figure 2) Figure 2. Adult Fruit and Vegetable Consumption by Age, Wicomico County, The adult female population of Wicomico County consumes more fruits and vegetables on a daily basis (26.1 percent) than the male population (19.6 percent) (see Figure 3). Figure 3. Adults Fruit and Vegetable Consumption by Gender, Wicomico County, Health Indicators Warehouse. (2013). Accessed: healthindicators.gov 6 Peninsula Regional Medical Center. Creating Health Communities Community Dashboard. Wicomico County. (2013). Accessed: 160

161 The percentage of fruit and vegetable consumption is approximately the same among white and black residents of Wicomico County (see Figure 4). Figure 4. Adult Fruit and Vegetable Consumption by Race/Ethnicity, Wicomico County, Of all adults in Dorchester County, 76.5 percent had consumed at least five servings of fruits and vegetables per day during This rate is higher than the state of Maryland s 72.1 percent of adults who consume five servings of fruits and vegetables daily (see Figure 5). Adult Fruit and Vegetable Consumption in Dorchester County, Maryland 72.1 Dorchester County Percentage of Adults who consume five servings of fruits and vegetables daily Figure 5. Adults who consume five servings of fruits and vegetables daily, Dorchester County,

162 In 2010, percent of the population in Wicomico County had low food access. This is a much higher percentage of low food access than in neighboring Dorchester County (9.84 percent). In comparison, 22.5 percent of the population in the state of Maryland experienced low food access in 2010 (see Figure 6). Figure 6. Population with low food access in the United States, Maryland, Dorchester County and Wicomico County, One measure of healthy food access and environmental influence on healthy behavior is access to grocery stores. The Community Commons defines grocery stores as supermarkets and smaller grocery stores primarily engaged in retailing a general line of food, such as canned and frozen foods; fresh fruits and vegetables; and fresh and prepared meats, fish, and poultry. Delicatessen-type establishments were included. Convenience stores and large general merchandise stores that also retail food, such as supercenters and warehouse club stores were excluded. In 2011, Wicomico County residents access to grocery stores was a relatively low 9.12 per 100,000 population, which was significantly lower than Dorchester County s grocery store access at per 100,000 population. When compared to grocery store access in the state of Maryland (19.5 per 100,000 population), both Dorchester County and Wicomico County residents had lower rates of grocery store access (see Figure 7). 7 7 Community Commons. Community Health Needs Assessment. (2013). Accessed: 162

163 Grocery Store Access U.S Maryland 19.5 Wicomico County 9.12 Dorchester County Rate Per 100,000 Population Figure 7. Grocery Store Access per 100,000 population in the United States, Maryland, Wicomico County, Dorchester County, In 2011, Wicomico County residents had access to fast food at a rate of per 100,000 population, while Dorchester County residents rate of fast food access was per 100,000 population. In comparison, the rate of fast food access in the state of Maryland was per 100,000 population, which is lower than the rate in Wicomico County, but higher than the rate in Dorchester County (see Figure 8). 7 Fast Food Access U.S Maryland Wicomico County Dorchester County Rate per 100,000 Population Figure 8. Fast Food Access per 100,000 populations in the United States, Maryland, Wicomico County, Dorchester County,

164 Local Resources Food Access There are several local efforts in Wicomico County and Dorchester County that address access to healthy food: Each county s Department of Human Resources provides Food Stamps for those who are income eligible. Breakfast in Maryland provides a healthy breakfast for schools in each county. After-school programs provide healthy snacks, beverages, and physical activity in conjunction with the Maryland Nutrition & Physical Activity Plan. Dorchester County provides food banks and Holiday Assistance (Thanksgiving and Christmas food vouchers) through the Salvation Army. The Food Bank provides food once every 6 months. The Agape Food Pantry is available for residents of Dorchester County and includes personal grooming products as well. Wicomico County, particularly in Salisbury, has over 26 Pantries and Soup Kitchens, mostly run by local faith communities. The Summer Food Service Program provides reimbursement for organizations providing meals and snacks for children. The Easton Market Square, an indoor farmers market, provides year round fresh and healthy food for the community. 164

165 Chapter 12. Housing Quality 165

166 Chapter 12. HOUSING QUALITY A person s living situation the condition of their homes and neighborhoods is a crucial determinant of health status. Low-quality housing may contain a range of environmental triggers that can cause or exacerbate health conditions, like asthma and allergies. Residential segregation has led certain neighborhoods particularly minority neighborhoods to face greater health risks due to living environments (see Figure 9). Research shows that variation in housing, neighborhoods, transportation, and homelessness are closely connected to health. Figure 9. Frequency of Housing Units with Physical Problems by Race, United States, 2007 Poor quality housing is a common source of asthma and allergy triggers as well as a variety of safety threats. The United States Department of Housing and Urban Development (HUD) identifies seven principles for a healthy home dry, clean, pest-free, safe, free of contaminants, ventilated, and well maintained. 8 HUD s healthy homes campaign targets asthma and allergies, mold and moisture, carbon monoxide and radon, lead, drinking water, and hazards in the home (including chemicals, pesticides, and accidental injuries). Other factors correlate with health issues in a less direct way, according to an analysis of the American Housing Survey and the National Health and Nutrition Examination Survey. 9 The presence of asthma is positively correlated with forced air furnaces and central air conditioning as well as bars on windows and broken windows. Families with lower socioeconomic status are more likely to encounter many of these environmental threats barred and broken windows, for example in their homes, which may contribute to higher incidence of certain diseases among low-income individuals. 8 United States Department of Housing and Urban Development. Making Homes Healthier for Families. Retrieved from 9 Jacobs, D. et al. The Relationship of Housing and Population Health: A 30-Year Retrospective Analysis. Environmental Health Perspectives. June

167 Outside of the home, one s neighborhood also plays an important role in one s health. Poor cardiovascular health is linked with several neighborhood characteristics, including lack of open space, presence of commercial or industrial facilities, noise, and poor outdoor air quality. One study found that living in a deprived neighborhood is associated with an increased risk of poor self-rated health status, poor mental health, and a higher average waist-to-hip ratio. 10 In this study, neighborhood deprivation was measured by four variables: unemployment, overcrowding in the home, non-car ownership, and non-home ownership. This study concluded that among those living in deprived communities, the poorest individuals were most impacted by the neighborhood, suggesting that poorer individuals rely more on collective neighborhood resources (defined as material and social resources, including services, job opportunities, and social supports) than people with higher incomes. Residential segregation is another important factor for neighborhoods. A study of children in metropolitan areas showed that white and Asian children live in different neighborhoods than black and Hispanic children. In the largest metropolitan areas, 72 percent of black children and 56 percent of Hispanic children do not live in fully integrated neighborhoods. In these same metropolitan areas, on average, black children live in neighborhoods with a poverty rate of 21 percent, while the poverty rate is 8 percent for white children, 19 percent for Hispanic children, and 11 percent for Asian children on average. 11 Poor neighborhood conditions may increase exposure to social risks and reduce access to resources. For example, weight-related health behavior is often linked to neighborhood environment. Residents are less likely to eat nutritious food if they do not have nearby access to healthy food options. Those living in segregated neighborhoods may disproportionately suffer the negative impacts that social and economic conditions can have on measures of health. Wicomico County Housing Statistics Renters spending 30 percent or more of household income on rent: 61.5 percent Homeowner vacancy rate: 9.6 percent (Source: biggestuscities.com ) Housing units: 41,192 Homeownership rate: 66.6 percent Housing units in multi-unit structures: 19.2 percent Median value of owner-occupied housing units: $195,400 Households: 37,220 Persons per household: 2.53 people (Source: U.S. Census, Quick Facts, 2010) 10 Stafford, M. and M. Marmot. Neighborhood Deprivation and Health: Does it Affect Us All Equally? International Journal of Epidemiology Acevedo-Garcia, D. et al. Children Left Behind: How Metropolitan Areas Are Failing America s Children. Harvard School of Public Health, Center for the Advancement of Health. January

168 Dorchester County Housing Statistics Renters spending 30 percent or more of household income on rent: 41.4 percent Homeowner vacancy rate: 18.3 percent (Source: biggestuscities.com) Housing units: 16,574 Homeownership rate: 69.8 percent Housing units in multi-unit structures: 14.3 percent Median value of owner-occupied housing units: $202,000 Households: 13,528 Persons per household: 2.4 people (Source: biggestuscities.com) Spotlight on Homelessness Perhaps the most extreme case of living situation having a negative impact on health is that of homelessness. According to Homeless Services in Maryland, 4.8 percent of the population in Wicomico County are homeless, and 0.2 percent of the population in Dorchester County are homeless (dhr.state.md.us). 12 People who experience homelessness have multidimensional health problems and often report unmet health needs, even if they have a usual source of care (see Figure 10). A national study of homeless adults found most unmet needs could be attributed to lack of insurance, but other factors were important as well. For example, additional predictors of unmet needs related to accessing care included food insufficiency and vision impairment. Figure 10. Prevalence of Unmet Health Care Needs among Homeless Adults, United States, Burt, M. et al. How many homeless people are there? Helping America s Homeless: Emergency Shelter or Affordable Housing? June

169 Local Resources Housing Quality Local efforts to improve living situations include those that promote home ownership, provide temporary financial or in-kind assistance to pay bills, and offer resources for homeless people. There are several local efforts in Wicomico and Dorchester Counties that address homelessness and housing quality: Residents in Wicomico and Dorchester Counties who are experiencing economic difficulties can receive assistance from the Salvation Army, the Community Action Agency, and Shore Up that helps the low income, working poor, and elderly with financial assistance and foreclosure counseling. The Maryland Energy Assistance Program (MEAP) assists with heating and electric bills. This program can assist in keeping residents in their homes by supporting them in paying bills. Shelters are available for those who are homeless. Delmarva Community Services, Inc. provides help for rent, mortgage payments, and energy bills. Wicomico County Housing Authority located in Salisbury, assists with HUD Section 8 Housing and Senior Citizen Housing. Project Home manages the Certified Adult Residential Environment (CARE) housing programs and provides supportive housing and case management to disabled adults, including persons with AIDS. The Rental Allowance Program (RAP) provides grants to give flat rent subsidies to low-income families that are either homeless or have an emergency housing need. The goal of this program is to enable households to move from homelessness to self-sufficiency. 169

170 Chapter 13. Education 170

171 Chapter 13. EDUCATION Disparities in disease incidence and mortality rates across education levels are prevalent. In fact, several studies have found that people with more education have longer life expectancies and lower disease rates than their less-educated counterparts. Because minority groups in Wicomico County, Dorchester County and in the state of Maryland tend to complete fewer years of education than whites, they may be at particular risk for worse health. Those with lower educational attainment (i.e., completed high school or less) have been found to have higher mortality rates due to chronic conditions, such as heart disease and cancer. 13 This trend persists across causes of death, including chronic obstructive pulmonary disease and cerebrovascular disease (see Figure 11). Individuals with at least some college education have a life expectancy of 81.6 years, approximately six years longer than those who completed high school or less (Meara, et al., 2008). Figure 11. Age-Standardized Deaths per 100,000 Americans, by Education, Race, and Cause (2000) Similar links also exist between education levels and disease incidence. For example, women with diabetes are less likely to have a high school diploma. In fact, 82 percent of diabetic women graduated from high school, compared to 87 percent of non-diabetic women Meara, E. et al. The Gap Gets Bigger: Challenges in Mortality and Life Expectancy, by Education, Health Affairs. March/April Centers for Disease Control and Prevention. Socioeconomic Status of Women with Diabetes United States, 2000, Morbidity and Mortality Weekly Report. February

172 Researchers have also found that better educated people are more likely to report good health status, and less likely to report depression. 15 With more education, people become less likely to engage in high-risk behaviors, such as smoking, drinking, and illegal drug use, and more likely to practice healthy habits, such as a nutritious diet and regular exercise (Cutler & Lleras-Muney, 2006). In fact, one study shows that four additional years of education reduces chances of death within a five-year period by nearly two percentage points (Cutler & Lleras-Muney, 2006). In Maryland, 52 percent of whites have above a high school education, compared to only 43 percent of blacks and 24 percent of Hispanics (see Figure 12) (U.S. Census Bureau, 2010). Figure 12. Educational Attainment by Race and Ethnicity, Maryland, Cutler, D. and A. Lleras-Muney. Education and Health: Evaluating Theories and Evidence. National Bureau of Economic Research. June

173 Education in Wicomico County Wicomico County performed slightly worse than the state baseline with regard to the percentage of students who graduate high school within four years (see Figure 13): SHIP Measure (County Baseline Source) Percentage of students who graduate high school four years after entering 9 th grade (MSDE 2010) County Baseline Maryland Baseline Maryland 2014 Target 81.1% 82.8% 86.1% Figure 13. SHIP Measure of Percentage of students who graduate high school four years after entering 9 th grade, Wicomico County, The overall graduation rate in Wicomico County is much lower than in the state of Maryland, and disparities in graduation rates are present among racial/ethnic groups. Of all racial and ethnic groups, Asians have the highest high school graduation rates (89.7 percent) and Hispanics/Latinos have the lowest high school graduation rates (72.4 percent) (see Figure 14). Figure 14. High School Graduation by Race/Ethnicity, Wicomico County, Department of Health and Mental Hygiene. State Health Improvement Process (SHIP). (2013). Accessed: 173

174 Additionally, there was a disproportionately higher percentage of Asians (48.2 percent) ages 25+ who have earned a bachelor s degree or higher from l compared to other racial/ethnic groups (see Figure 15). Figure 15. People 25 and old with a Bachelor s Degree or Higher by Race/Ethnicity, Wicomico County, Regarding student scores on the Maryland School Assessment, Asians in Wicomico County had the highest percentage of eighth grade students that are proficient or above in reading (95.0 percent), and whites had the second highest percentage at 87.4 percent. Blacks/African Americans and Hispanics had the lowest percentage of eighth grade students that are proficient or above in reading at 60.3 percent and 70.6 percent, respectively (see Figure 16). Figure 16. Percent of 8 th Grade Students Proficient in Reading by Race/Ethnicity, Wicomico County,

175 Education in Dorchester County Dorchester County performed worse than the state baseline with regard to the percentage of students who graduate high school four years after entering 9 th grade at 78.5 percent, compared to 82.8 percent statewide (see Figure 17). Dorchester County s Hispanic residents have the lowest percentage of students who graduate high school at 57.1 percent compared to Dorchester County s white residents at 86.4 percent 17. SHIP Measure (County Baseline Source) Percentage of students who graduate high school four years after entering 9 th grade (MSDE 2010) County Baseline Maryland Baseline Maryland 2014 Target 78.5% 82.8% 86.1% Percentage of children who enter kindergarten ready to learn 79% 83% 85% Figure 17. SHIP Measure of Percentage of students who graduate high school four years after entering 9 th grade and Percentage of children who enter kindergarten ready to learn, Dorchester County, Dorchester County also performed worse than the state baseline with regard to the percentage of children who enter kindergarten ready to learn as well, at 79 percent, compared to 83 percent statewide (see Figure 17). In Dorchester County, 100 percent of Asian children entered kindergarten ready to learn, compared to 72 percent of both black/african American and white children, and 70 percent of Hispanic children 17. Some minority groups may have fewer educational opportunities, such as limited access to good schools, after-school programs, and positive role models. Residential segregation on the basis of race and ethnicity can contribute to disparities in quality of education, since school districts are typically based on the location of one s residence. Black and Hispanic children experience higher levels of residential segregation and associated educational challenges compared to white and Asian children. 17 Furthermore, these neighborhoods often have fewer highly educated adults, which can negatively impact children s perceptions about the educational opportunities available to them (Acevedo- Garcia, et al., 2007). At the national and local levels, social interventions can improve educational attainment by increasing access to education for people of all ages and backgrounds. In Adventist Behavioral Health Eastern Shore s CBSA, organizations target both children and adults through a range of educational programs, such as after-school programs and English as a second language (ESL) courses, to supplement existing public school options. Some of these educational programs are offered by organizations focused on housing issues, further highlighting the interrelated nature of social determinants. 17 Acevedo-Garcia, D. et al. Children Left Behind: How Metropolitan Areas Are Failing America s Children. Harvard School of Public Health, Center for the Advancement of Health. January

176 Local Resources Education In Adventist Behavioral Health Eastern Shore s CBSA, community groups work to reduce the influence of educational disparities by offering supplemental education programs for all ages. Among teenagers and young adults, educational disparities are often the result of students dropping out of school. Several local programs aim to keep students in school. Such programs aim to improve the education of the community. These efforts should have a positive impact on health by (1) encouraging additional years of education for the participants; (2) helping participants get better jobs in the long term with employers who are more understanding of health needs and more likely to offer health insurance; and (3) increasing health literacy and understanding of health improvement. The local efforts in Wicomico and Dorchester Counties that improve the education of the community are as follows: The Maryland One Stop Career Centers in Dorchester County and Wicomico County offers Adult Education and Literacy services and administers the statewide GED testing program. They also provide English as a Second Language (ESL) training in various locations in the area. Dorchester County Public Schools works in partnership with the community to provide tutors, decrease the suspension rate, and expand mental health services for students. They also reach out to homeless students. Wicomico County Board of Education provides special outreach to homeless children. Pre-school For All is a Pre-kindergarten Classroom to provide early learning opportunities to the community. The Wicomico County Library has a Testing and Education Center providing a Language Lab Center, which has computers for adult ESL students to learn computer skills. Dorchester County s First Steps program is a multi-disciplinary, early intervention program for children ages 3 to 6 and their families for tutoring, counseling, and parent education. The School Community/Multi-Service Centers of Dorchester County are designed to help children be successful through tutoring, computer-assisted instruction, and school recreational activities. 176

177 Chapter 14. Transportation 177

178 Chapter 14. TRANSPORTATION Lack of reliable transportation is a common barrier to accessing health care. For lowincome people, even those with insurance, problems accessing care remain when they do not have a dependable source of transportation. Unreliable or unavailable public transportation can prevent individuals from seeking care and cause them to miss scheduled appointments. This problem has been well documented across low-income groups from rural to urban areas and across race and ethnicity. For example, the Children s Health Fund reported that lack of transportation was among the top three persistent barriers to care for individuals across the nation. 18 Another study in Houston, Texas showed that people who do not use a car to get to medical appointments are more than three times more likely to miss an appointment compared to someone who uses a car. 19 The rate of pedestrian injuries on public roads in Wicomico County is significantly lower than the state baseline. The rate in Dorchester County is too small to compare to the state and national baselines (see Figure 18). Figure 18. SHIP Measure of Rate of injuries to pedestrians per 100,000 in Wicomico County and Dorchester County, The pedestrian death rate in Wicomico County is 0.0 deaths per 100,000 population, compared to 1.8 deaths per 100,000 in the state of Maryland. The Healthy People 2020 target is to reduce pedestrian deaths to 1.3 deaths/100,000 population (Healthy Communities Institute, Fatality Analysis Reporting System, 2010). 18 Grant, R. et al. Getting There, Getting Care: Transportation and Workforce Barriers to Child Healthcare in America. The Children s Health Fund Yang, S. et al. Transportation Barriers to Accessing Healthcare for Urban Children. Department of Pediatrics, Baylor College of Medicine. November