Examining the Health of Monroe County

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2 Examining the Health of Monroe County

3 FOREWORD The Monroe County Building Healthy Communities Coalition and its members are pleased to present the 2015 Health Assessment of our community. This comprehensive Community Health Assessment provides a snap shot of where Monroe County residents currently stand in terms of their well-being as well as their health habits. Additionally, the local data provides a comparison with regional, state and national data. Because the statistics found in this report provide a clearer, more complete view of our collective health, the report can serve as a call to action for our residents, health professionals, employers, policy makers, community and religious leaders. This document will be used by the Monroe County Building Healthy Communities Coalition in collaboration with multiple community partners to complete a Health Improvement Plan for Monroe County. The Health Improvement Plan will prioritize strategies to strengthen the local health system and support individuals in becoming and staying healthy. Through the Mobilizing for Action, Planning and Partnerships (MAPP) process, the Health Improvement Plan will be developed. The MAPP process comes from National Association of County & City Officials (NACCHO). The Building Healthy Communities Coalition is committed to its vision of empowering Monroe County residents to live healthy lifestyles and its mission of improving the health of Monroe County residents by promoting physical activity, healthy eating and safe environments through community collaboration. This report offers assistance in identifying areas of opportunity to make Monroe County a healthier place to live, work and play. We would like to thank the partnerships and agencies (list follows) that worked on this project and especially the residents who answered the survey. Without all of you, this comprehensive health assessment would not have been possible. We also encourage you to use this report in planning and collaboration with partners to improve the health of our community. FOREWORD Sincerely, Kim Comerzan Health Officer/Director Monroe County Health Department Annette Philips President ProMedica Monroe Regional Hospital

4 Funding for the Monroe County Health Assessment Provided by: Monroe County Health Plan Member Organizations of the Monroe County Building Healthy Communities Coalition: Mercy Memorial Hospital Health System City of Monroe Monroe County Health Department Area Agency on Aging Monroe County Health Plan United Way of Monroe Monroe County Substance Abuse Coalition Relay For Life Human Services Collaborative Network Great Start Collaborative American Cancer Society of SE Michigan Monroe County Family YMCA Monroe County Mental Health Authority Monroe County Community College Monroe County Head Start/Early Head Start Family Medical Center of Michigan Child Advocacy Network (CAN) Council Monroe Center for Healthy Aging Monroe County Planning Commission Department of Human Services Monroe County Board of Commissioners Community Foundation Catholic Charities of Southeast Michigan Monroe Public Schools Bedford Public Schools Jefferson Public Schools Ida Public Schools Dundee Public Schools Mason Consolidated Public Schools Summerfield Public Schools Whiteford Public Schools American Heart Association Monroe County Intermediate School District (ISD) American Red Cross Monroe County Commission on Aging Michigan State Police Monroe County MSU Extension Human Services Collaborative Network Contact Information Jamie R. Dean, B.S., M.S.Ed. Monroe County Health Department 2353 South Custer Rd. Monroe, MI Phone: (734)

5 Project Management, Secondary Data, Data Collection, and Report Development Hospital Council of Northwest Ohio Britney L. Ward, MPH Director of Community Health Improvement Michelle Von Lehmden Health Assessment Coordinator Derick Sekyere Graduate Assistant Data Collection & Analysis James H. Price, Ph.D., MPH Professor Emeritus of Health Education University of Toledo Timothy R. Jordan, Ph.D., M.Ed. Professor of Health Education University of Toledo Margaret Wielinski, MPH Assistant Director of Community Health Improvement Tessa Elliott Graduate Assistant Anna Crisp Undergraduate Assistant Joseph A. Dake, Ph.D., MPH Professor and Chair of Health Education University of Toledo To see Monroe County data compared to other counties, please visit the Hospital Council of Northwest Ohio s Data Link website at FOREWORD

6 TABLE OF CONTENTS EXECUTIVE SUMMARY PAGES 5-15 TREND SUMMARY PAGES Adult Health (Ages 19 and Over) HEALTH STATUS PERCEPTIONS PAGES HEALTH CARE COVERAGE PAGES HEALTH CARE ACCESS AND UTILIZATION PAGES CARDIOVASCULAR HEALTH PAGES CANCER PAGES DIABETES PAGES ASTHMA PAGES ARTHRITIS PAGES WEIGHT STATUS PAGES TOBACCO USE PAGES ALCOHOL CONSUMPTION PAGES DRUG USE PAGES WOMEN S HEALTH PAGES MEN S HEALTH PAGES PREVENTIVE MEDICINE AND HEALTH SCREENINGS PAGES SEXUAL BEHAVIOR AND PREGNANCY OUTCOMES PAGES QUALITY OF LIFE PAGES SOCIAL CONTEXT AND SAFETY PAGES MENTAL HEALTH AND SUICIDE PAGES ORAL HEALTH PAGES PARENTING PAGE 96 Youth Health (Ages 12-18) WEIGHT CONTROL PAGES TOBACCO USE PAGES ALCOHOL CONSUMPTION PAGES DRUG USE PAGES SEXUAL BEHAVIOR AND TEEN PREGNANCY OUTCOMES PAGES MENTAL HEALTH AND SUICIDE PAGES YOUTH SAFETY PAGES YOUTH VIOLENCE ISSUES PAGES Appendices HEALTH ASSESSMENT INFORMATION SOURCES APPENDIX I PAGES LIST OF ACRONYMS AND TERMS APPENDIX II PAGES WEIGHTING METHODS APPENDIX III PAGES SCHOOL PARTICIPATION APPENDIX IV PAGE 132 DEMOGRAPHIC PROFILE APPENDIX V PAGE 133 DEMOGRAPHICS AND HOUSEHOLD INFORMATION APPENDIX VI PAGES

7 EXECUTIVE SUMMARY This executive summary provides an overview of health-related data for Monroe County adults (19 years of age and older) and youth (grades 6-12) who participated in a county-wide health assessment survey during spring The findings are based on self-administered surveys using structured questionnaires. The questions were modeled after the survey instruments used by the Centers for Disease Control and Prevention for their national and state Behavioral Risk Factor Surveillance System (BRFSS) and Youth Risk Behavioral Surveillance System (YRBSS). The Hospital Council of Northwest Ohio collected the data, guided the health assessment process and integrated sources of primary and secondary data into the final report. Primary Data Collection Methods DESIGN This community health assessment was cross-sectional in nature and included a written survey of adults and youth within Monroe County. From the beginning, community leaders were actively engaged in the planning process and helped define the content, scope, and sequence of the study. Active engagement of community members throughout the planning process is regarded as an important step in completing a valid needs assessment. INSTRUMENT DEVELOPMENT Two survey instruments were designed and pilot tested for this study. As a first step in the design process, health education researchers from the University of Toledo and staff members from the Hospital Council of NW Ohio met to discuss potential sources of valid and reliable survey items that would be appropriate for assessing the health status and health needs of adults and youth. The investigators decided to derive the majority of the adult survey items from the BRFSS and YRBSS. This decision was based on being able to compare local data with state and national data. The Project Coordinator from the Hospital Council of NW Ohio conducted a series of meetings with the planning committee from Monroe County. During these meetings, banks of potential survey questions from the BRFSS and YRBSS surveys were reviewed and discussed. Based on input from the Monroe County planning committee, the Project Coordinator composed a draft survey containing 115 items for the adult survey and 76 items for the youth survey. The drafts were reviewed and approved by health education researchers at the University of Toledo. SAMPLING Adult Survey Adults ages 19 and over living in Monroe County were used as the sampling frame for the adult survey. Since U.S. Census Bureau age categories do not correspond exactly to this age parameter, the investigators calculated the population of those 18 years and over living in Monroe County. There were 106,973 persons ages 18 and over living in Monroe County. The investigators conducted a power analysis to determine what sample size was needed to ensure a 95% confidence level with a corresponding margin of error of 5% (i.e., we can be 95% sure that the true population responses are within a 5% margin of error of the survey findings.) A sample size of at least 383 adults was needed to ensure this level of confidence. The random sample of mailing addresses of adults from Monroe County was obtained from Allegra Marketing Services in Louisville, KY. SAMPLING Adolescent Survey There were 15,972 persons ages 12 to 18 years old living in Monroe County. A sample size of 375 adolescents was needed to ensure a 95% confidence interval with a corresponding 5% margin of error. Students were randomly selected and surveyed in the schools. EXECUTIVE SUMMARY 5

8 PROCEDURE Adult Survey Prior to mailing the survey to adults, an advance letter was mailed to 1,200 adults in Monroe County. This advance letter was personalized, printed on Building Healthy Communities Coalition stationery and was signed by John Kibble, Vice President, ProMedica Monroe Regional Hospital, and Kim Comerzan, Health Officer, Monroe County Health Department. The letter introduced the county health assessment project and informed the readers that they may be randomly selected to receive the survey. The letter also explained that the respondents confidentiality would be protected and encouraged the readers to complete and return the survey promptly if they were selected. Three weeks following the advance letter, a three-wave mailing procedure was implemented to maximize the survey return rate. The initial mailing included a personalized hand signed cover letter (on Building Healthy Communities Coalition stationery) describing the purpose of the study; a questionnaire printed on colored paper; a self-addressed stamped return envelope; and a $2 incentive. Approximately three weeks after the first mailing, a second wave mailing included another personalized cover letter encouraging them to reply, another copy of the questionnaire on colored paper, and another reply envelope. A third wave postcard was sent three weeks after the second wave mailing. Surveys returned as undeliverable were not replaced with another potential respondent. The response rate for the mailing was 38% (n=444: CI=+4.64). This return rate and sample size means that the responses in the health assessment should be representative of the entire county. PROCEDURE Adolescent Survey The survey was approved by all superintendents. Schools and grades were randomly selected. Each student in that grade had to have an equal chance of being in the class that was selected, such as a general English or health class. Classrooms were chosen by the school principal. Passive permission slips were mailed home to parents of any student whose class was selected to participate. The response rate was 92% (n=456: CI=+4.52) DATA ANALYSIS Individual responses were anonymous and confidential. Only group data are available. All data was analyzed by health education researchers at the University of Toledo using SPSS Crosstabs were used to calculate descriptive statistics for the data presented in this report. To be representative of Monroe County, the adult data collected was weighted by age, gender, race, and income using 2010 census data. Multiple weightings were created based on this information to account for different types of analyses. For more information on how the weightings were created and applied, see Appendix iii. LIMITATIONS As with all county assessments, it is important to consider the findings in light of all possible limitations. First, the Monroe County adult assessment had a high response rate. However, if any important differences existed between the respondents and the non-respondents regarding the questions asked, this would represent a threat to the external validity of the results (the generalizability of the results to the population of Monroe County). If there were little to no differences between respondents and non-respondents, then this would not be a limitation. Second, it is important to note that, although several questions were asked using the same wording as the CDC questionnaires, the adult data collection method differed. CDC adult data were collected using a set of questions from the total question bank and adults were asked the questions over the telephone rather than as a mail survey. 6

9 Data Summary HEALTH PERCEPTIONS In 2015, over half (55%) of the Monroe County adults rated their health status as excellent or very good. Conversely, 12% of adults, increasing to 19% of those over the age of 60, described their health as fair or poor. 100% 80% 60% 40% 20% 0% *Respondents were asked: Would you say that in general your health is excellent, very good, good, fair or poor? HEALTH CARE COVERAGE The 2015 Health Assessment data has identified that 9% of Monroe County adults were without health care coverage. Those most likely to be uninsured were adults ages 30-59, those with an income level under $25,000, and females. In Monroe County, 12.9% of residents live below the poverty level (Source: U.S. Census, American Community Survey 1 Year Estimate, 2013). 20% 10% 0% 12% 11% 14% 33% 36% 31% 55% 53% 55% 22% 78% 36% 51% 38% 33% 43% 45% Total Males Females Under years 60 & Older Income <$25K 9% 6% Monroe County Adult Health Perceptions* 0% 13% 19% 22% Excellent/Very Good Good Fair/Poor Uninsured Monroe County Adults 13% 8% 12% Total Males Females Under years 60 & Older Income <$25K 2% 12% 10% 36% 54% Income $25K Plus 9% Income $25K Plus EXECUTIVE SUMMARY 7

10 HEALTH CARE ACCESS The 2015 Health Assessment project identified that 64% of Monroe County adults had visited a doctor for a routine checkup in the past year. 63% of adults went outside of Monroe County for health care services in the past year. CARDIOVASCULAR HEALTH The 2015 Monroe County Health Assessment found that 6% of adults had survived a heart attack and 3% had survived a stroke at some time in their life. Nearly one-third (32%) of Monroe County adults had been diagnosed with high blood pressure, 35% had high blood cholesterol, 31% were obese, and 14% were smokers, four known risk factors for heart disease and stroke. Heart disease (25%) and stroke (5%) accounted for 30% of all Monroe County adult deaths in 2012 (Source: MDCH, Vital Statistics). CANCER In 2015, 12% of Monroe County adults had been diagnosed with cancer at some time in their life. Michigan Department of Community Health statistics indicate that from , a total of 1,571 Monroe County residents died from cancer, the second leading cause of death in the county. The American Cancer Society advises that not using tobacco products, maintaining a healthy weight, adopting a physically active lifestyle, eating more fruits and vegetables, limiting alcoholic beverages and early detection may reduce overall cancer deaths. Monroe County Leading Types of Death 2013 Total Deaths: Cancer (26% of all deaths) 2. Heart Disease (25%) 3. Chronic Lower Respiratory Diseases (6%) 4. Accidents, Unintentional Injuries (6%) 5. Stroke (5%) (Source: MDCH, Vital Statistics, updated ) Monroe County Incidence of Cancer, 2011 All Types: 642 cases Lung and Bronchus: 114 cases (18%) Prostate: 94 cases (15%) Breast: 89 cases (14%) Colon and Rectum: 53 cases (8%) In 2012, there were 332 cancer deaths in Monroe County. (Source: Michigan Community Health Information Cancer) DIABETES In 2015, 13% of Monroe County adults had been diagnosed with diabetes. ARTHRITIS According to the Monroe County survey data, 38% of Monroe County adults were diagnosed with arthritis. According to the 2013 BRFSS, 31% of Michigan adults and 25% of U.S. adults were told they have arthritis. ASTHMA In 2015, 17% of Monroe County adults had been diagnosed with asthma. ADULT WEIGHT STATUS The 2015 Health Assessment identified that 73% of Monroe County adults were overweight or obese based on Body Mass Index (BMI). Nearly one-third (31%) of Monroe County adults were obese. The 2013 BRFSS indicates that 32% of Michigan and 29% of U.S. adults were obese by BMI. More than half (53%) of adults were trying to lose weight. 8

11 100% 80% 60% 40% 20% 0% (Percentages may not equal 100% due to the exclusion of data for those who were classified as underweight) ADULT TOBACCO USE In 2015, 14% of Monroe County adults were current smokers and 31% were considered former smokers. In 2014, the American Cancer Society (ACS) stated that tobacco use was the most preventable cause of death worldwide, and is responsible for the deaths of approximately half of long-term users. Each year, tobacco use is responsible for almost 6 million premature deaths, 80% of which are in low-and middle-income countries, and by 2030, this number is expected to increase to 8 million. (Source: Cancer Facts & Figures, American Cancer Society, 2014) 100% 80% 60% 40% 20% 0% 31% 28% 42% 53% 26% 19% Monroe County Adult BMI Classifications 33% 32% 34% 8% 50% 35% 37% 39% 29% 47% 23% 24% 41% 44% 15% Total Male Female Under Years 60 & Older Income < $25K 55% 31% 47% 40% 14% 13% 15% Normal Overweight Obese Monroe County Adult Smoking Behaviors 61% 24% 85% 4% 11% 53% 31% 16% 13% 40% 37% 47% 26% 37% Total Male Female Under Years 60 & Older Income <$25K Current smoker Former smoker Never smoked Respondents were asked: Have you smoked at least 100 cigarettes in your entire life? If yes, do you now smoke cigarettes every day, some days or not at all? 29% 44% 27% Income $25K Plus 54% 35% 11% Income $25K Plus EXECUTIVE SUMMARY 9

12 ADULT ALCOHOL CONSUMPTION In 2015, the Health Assessment indicated that 12% of Monroe County adults were considered frequent drinkers (drank an average of three or more days per week, per CDC guidelines). 40% of adults who drank had five or more drinks (for males) or 4 or more drinks (for females) on one occasion (binge drinking) in the past month. Four percent of adults drove after having perhaps too much to drink. 60% Monroe County Adult Drinkers Who Binge Drank in Past Month* 52% 40% 40% 41% 40% 43% 46% 40% 27% 20% 0% Total Males Females Under Years 60 & Older Income <$25K Income $25K Plus *Based on adults who have drunk alcohol in the past month. Binge drinking is defined as having five or more drinks (for males) or four or more drinks (for females) on an occasion. Adults must have reported drinking five or more drinks (for males) or four or more drinks (for females) on an occasion at least once in the previous month. ADULT MARIJUANA AND OTHER DRUG USE In 2015, 7% of Monroe County adults had used marijuana during the past 6 months. 11% of adults had used medication not prescribed for them or took more than prescribed to feel good or high and/or more active or alert during the past 6 months. 20% Monroe County Adult Marijuana Use in Past 6 Months 15% 15% 12% 10% 7% 9% 6% 7% 7% 8% 5% 0% Total Males Females Under Years 60 & Older Income <$25K Income $25K Plus 10

13 WOMEN S HEALTH In 2015, more than half (54%) of Monroe County women over the age of 40 reported having a mammogram in the past year. 64% of Monroe County women ages 19 and over had a clinical breast exam and 56% had a Pap smear to detect cancer of the cervix in the past year. The Health Assessment determined that 2% of women survived a heart attack and 3% survived a stroke at some time in their life. More than one-quarter (26%) had high blood pressure, 34% had high blood cholesterol, 33% were obese, and 15% were identified as smokers, known risk factors for cardiovascular diseases. 100% 75% 50% 25% 0% 37% MEN S HEALTH 64% Monroe County Women's Health Exams Within the Past Year 56% Total Under & Older Income <$25K Income >$25K In 2015, 60% of Monroe County males over the age of 50 had a Prostate-Specific Antigen (PSA) test. Major cardiovascular diseases (heart disease and stroke) accounted for 28% and cancers accounted for 30% of all male deaths in Monroe County in The Health Assessment determined that 12% of men survived a heart attack and 2% survived a stroke at some time in their life. Nearly two-fifths (39%) of men had been diagnosed with high blood pressure, 37% had high blood cholesterol, and 13% were identified as smokers, which, along with obesity (28%), are known risk factors for cardiovascular diseases. PREVENTIVE MEDICINE AND HEALTH SCREENINGS More than half (55%) of adults ages 65 and older had a pneumonia vaccination at some time in their life. Three-fifths (61%) of adults ages 50 and older had a colonoscopy/sigmoidoscopy within the past 5 years. ADULT SEXUAL BEHAVIOR & PREGNANCY OUTCOMES 4% 72% 68% 54% 59% 39% 40% In 2015, over two-thirds (70%) of Monroe County adults had sexual intercourse. Six percent of adults had more than one partner. Prevalence estimates suggest that young people aged years acquire half of all new STDs and that 1 in 4 sexually active adolescent females have an STD, such as chlamydia or human papillomavirus (HPV) (Source: CDC, STDs in Adolescents and Young Adults, 2014 STD Surveillance). 48% 57% 50% Mammogram Breast Exam Pap Smear 68% 57% EXECUTIVE SUMMARY 11

14 QUALITY OF LIFE In 2015, 20% of Monroe County adults were limited in some way because of a physical, mental or emotional problem. SOCIAL CONTEXT In 2015, 9% of Monroe County adults were threatened or abused in the past year. 50% of adults kept a firearm in or around their home. MENTAL HEALTH AND SUICIDE In 2015, 3% of Monroe County adults considered attempting suicide. 9% of adults had a period of two or more weeks when they felt so sad or hopeless nearly every day that they stopped doing usual activities. ORAL HEALTH The 2015, four-fifths (80%) of Monroe County adults had visited a dentist or dental clinic in the past year. The 2012 BRFSS reported that 67% of U.S. adults and 68% of Michigan adults had visited a dentist or dental clinic in the previous twelve months. More than three-quarters (79%) of Monroe County youth in grades 6-12 had visited the dentist for a check-up, exam, teeth cleaning, or other dental work in the past year. PARENTING The 2015 Health Assessment project identified that 78% of parents discussed bullying with their 6-to-17 year-old in the past year. More than four-fifths (83%) of parents indicated their child was physically active for at least 60 minutes 3 or more days per week. YOUTH WEIGHT STATUS The 2015 Health Assessment identified that 17% of Monroe County youth were obese, according to Body Mass Index (BMI) by age. When asked how they would describe their weight, 30% of Monroe County youth reported that they were slightly or very overweight. 68% of youth were exercising for 60 minutes on 3 or more days per week. 89% of youth were involved in extracurricular activities. 100% Monroe County Youth BMI Classifications 2% 1% 2% 4% 1% 3% 80% 60% 70% 69% 71% 81% 67% 66% 40% 20% 0% 12% 9% 15% 10% 16% 17% 21% 8% 11% 18% 21% 7% Total Male Female 13 or younger 14 to & Older Obese Overweight Normal Weight Underweight 12

15 YOUTH TOBACCO USE The 2015 Health Assessment identified that 7% of Monroe County youth in grades 6-12 were smokers, increasing to 17% of those ages 17 and older. Of those 6th -12th grade youth who currently smoked, 68% had tried to quit. YOUTH ALCOHOL CONSUMPTION In 2015, the Health Assessment results indicated that 48% of Monroe County youth in grades 6-12 had drank at least one drink of alcohol in their life, increasing to 68% of youth seventeen and older. 27% of those 6th-12th graders who drank, took their first drink at 12 years or younger. 21% of all Monroe County 6th-12th grade youth and 41% of those over the age of 17 had at least one drink in the past 30 days. Half (50%) of the 6th-12th grade youth who reported drinking in the past 30 days had at least one episode of binge drinking.10% of all youth drivers had driven a car in the past month after they had been drinking alcohol. 100% 80% 60% 40% 20% 0% 30% 20% 10% 0% 7% Monroe County Youth Who Are Current Smokers 8% 6% Total Male Female 12 to to & Older 50% Monroe County Youth Current Drinkers Who Binge Drank in Past Month* 59% 38% Total Male Female 12 to to & Older *Based on all current drinkers. Binge drinking is defined as having five or more drinks on an occasion. 2% 50% 5% 39% 17% 60% EXECUTIVE SUMMARY 13

16 YOUTH MARIJUANA AND OTHER DRUG USE In 2015, 12% of Monroe County 6th-12th grade youth had used marijuana at least once in the past 30 days, increasing to 27% of those ages 17 and older. 6% of youth used medications that were not prescribed for them or took more than prescribed to get high at some time in their life. 15% Monroe County Youth Lifetime Drug Use 10% 5% 0% 5% 4% 4% 3% 2% 2% 2% 2% 2% 1% 1% 1% 1% 1% 0% Cocaine Heroin Meth Steroids Inhalants Total Male Female YOUTH SEXUAL BEHAVIOR & PREGNANCY OUTCOMES In 2015, just over one-quarter (26%) of Monroe County youth have had sexual intercourse, increasing to 57% of those ages 17 and over. 30% of youth had participated in oral sex and 5% had participated in anal sex. 23% of youth participated in sexting. Of those who were sexually active, 58% had multiple sexual partners. Four Monroe County schools did not ask sexual behavior questions. 75% Monroe County Youth Who Had Sexual Intercourse 57% 50% 25% 26% 20% 32% 15% 1% 0% Total Male Female 13 or Younger 14 to & Older 14

17 YOUTH MENTAL HEALTH AND SUICIDE In 2015, the Health Assessment results indicated that 11% of Monroe County 6th-12th grade youth had seriously considered attempting suicide in the past year and 6% admitted actually attempting suicide in the past year. 50% 40% 30% 20% 10% 0% YOUTH SAFETY In 2015, 19% of youth had ridden in a car driven by someone who had been drinking alcohol in the past month and 10% of youth drivers had driven after drinking alcohol. 32% of youth drivers texted while driving. YOUTH VIOLENCE In Monroe County, 21% of youth had been involved in a physical fight in the past year. 5% of youth had been threatened or injured with a weapon on school property in the past year. 44% of youth had been bullied in the past year and 28% had been bullied on school property. 75% 50% 25% 0% 23% 14% 33% Total Male Female 12 to to & Older 44% Monroe County Youth Who Felt Sad or Hopeless Almost Every Day for Two Weeks or More in a Row 19% 20% Monroe County Youth Bullied in the Past Year 38% 50% Total Male Female 12 to to & Older 53% 41% 32% 34% EXECUTIVE SUMMARY 15

18 Adult І TREND SUMMARY Adult Variables Health Status Monroe County 2015 Michigan 2013 U.S Rated health as excellent or very good 55% 51% 52% Rated general health as fair or poor 12% 18% 17% Average days that physical health not good in past month * 3.7 ** Average days that mental health not good in past month * 3.5 ** Health Care Coverage Uninsured 9% 14% 17% Arthritis, Asthma & Diabetes Has been diagnosed with diabetes 13% 11% 11% Has been diagnosed with asthma 17% 17% 14% Cardiovascular Health Had a heart attack 6% 5% 4% Had a stroke 3% 4% 3% Has been diagnosed with high blood pressure 32% 35% 31% Has been diagnosed with high blood cholesterol 35% 41% 38% Had blood cholesterol checked within the past 5 years 81% 79% 76% Alcohol Consumption Had at least one alcoholic beverage in past month 54% 57% 55% Binged in past month (5 or more drinks in a couple of hours on an occasion) 21% 19% 17% Tobacco Use Current smoker (currently smoke some or all days) 14% 21% 19% Former smoker (smoked 100 cigarettes in lifetime & now do not smoke) 31% 27% 25% Preventive Medicine Had a pneumonia vaccine in lifetime (age 65 and older) 55% 69% 70% Had a flu vaccine in the past year (ages 65 and over) 76% 57% 63% Had a clinical breast exam in the past two years (age 40 and older) 76% 80% ** 77% ** Had a mammogram in the past two years (age 40 and older) 72% 77%* 74%* Had a pap smear in the past three years 84% 80%* 78%* Had a PSA test within the past two years (age 40 & over) 58% 48%* 45%* Weight Status Overweight 42% 35% 35% Obese 31% 32% 29% Quality of Life Limited in some way because of physical, mental or emotional problem 20% 23% 20% Oral Health Adults who have visited the dentist in the past year 80% 68%* 67%* Adults who have had one or more permanent teeth removed 35% 45% 43% N/A- not available *2012 BRFSS Data ** 2010 BFRSS Data 16

19 Youth І TREND SUMMARY Youth Variables Monroe County 2015 (6 th -12 th ) Alcohol Consumption Monroe County 2015 (9 th -12 th ) Michigan 2013 (9 th -12 th ) U.S (9 th -12 th ) Ever tried alcohol 48% 58% 60% 66% Current drinker 21% 28% 28% 35% Binge drinker (of all youth) 11% 14% 17% 21% Drank for the first time before age 13 (of all youth) 12% 12% 14% 19% Rode with someone who was drinking 19% 22% 20% 22% Drank and drove (of youth drivers) 10% 10% 6% 10% Obtained the alcohol they drank by someone giving it to them 33% 40% 33% 42% Tobacco Use Ever tried cigarettes 24% 31% 36% 41% Current smokers 7% 9% 12% 16% Tried to quit smoking (of smokers) 68% 54% 52% 48% Smoked cigarettes on 20 or more days during the past month (of all youth) 2% 2% 4% 6% Smoked a whole cigarette for the first time before the age of 13 (of all youth) 5% 5% 8% 9% Sexual Behavior Ever had sexual intercourse 26% 35% 38% 47% Used a condom at last intercourse 57% 58% 61% 59% Used birth control pills at last intercourse 35% 37% 22% 19% Did not use any method to prevent pregnancy during last sexual intercourse 11% 11% 9% 14% Had four or more sexual partners (of all youth) 8% 11% 8% 15% Had sexual intercourse before age 13 (of all youth) 3% 4% 3% 6% Drug Use Youth who used marijuana in the past month 12% 16% 18% 23% Ever used methamphetamines 1% 1% 3% 3% Ever used cocaine 2% 3% 4% 6% Ever used heroin 1% 2% 3% 2% Ever used steroids 2% 3% 3% 3% Ever used inhalants 4% 4% 7% 9% Ever misused medications 6% 8% 16% 18% Ever used ecstasy/mdma 2% 2% N/A 7% Ever been offered, sold, or given an illegal drug by someone on school property in the past year 8% 11% 24% 22% Mental Health Youth who had seriously considered attempting suicide in the past year 11% 11% 16% 17% Youth who had attempted suicide in the past year 6% 5% 9% 8% Suicide attempt resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse 1% 1% 3% 3% (of all youth) Youth who felt sad or hopeless almost every day for 2 or more weeks in a row 23% 25% 27% 30% TREND SUMMARY N/A Not available 17

20 N/A Not available Youth Variables Monroe County 2015 (6 th -12 th ) Weight Control Monroe County 2015 (9 th -12 th ) Michigan 2013 (9 th -12 th ) U.S (9 th -12 th ) Obese 17% 19% 13% 14% Overweight 12% 13% 16% 17% Described themselves as slightly or very overweight 30% 30% 29% 31% Trying to lose weight 46% 46% 45% 48% Went without eating for 24 hours or more 3% 4% 13% 13% Took diet pills, powders, or liquids without a doctor s advice 2% 3% 6% 5% Vomited or took laxatives 2% 2% 5% 4% Physically active at least 60 minutes per day on every day in past week 25% 27% 27% 27% Physically active at least 60 minutes per day on 5 or more days in past week 48% 50% 50% 47% Did not participate in at least 60 minutes of physical activity on any day in past week 13% 14% 15% 15% Watched TV 3 or more hours per day 22% 23% 27% 33% Unintentional Injuries and Violence Carried a weapon in past month 12% 13% 16% 18% Carried a weapon on school property in past month 3% 3% 4% 5% Been in a physical fight in past year 21% 18% 22% 25% Been in a fight on school property in past year 7% 6% 7% 8% Threatened or injured with a weapon on school property in past year 5% 5% 7% 7% Did not go to school because felt unsafe 5% 5% 7% 7% Electronically/cyber bullied in past year 10% 11% 19% 15% Bullied in past year 44% 40% N/A N/A Bullied on school property in past year 28% 22% 25% 20% Hit, slapped, or physically hurt on purpose by their boyfriend or girlfriend in past year 4% 3% 9% 10% Preventive Care Used an indoor tanning device in past year 8% 11% N/A 13% 18

21 Adult І HEALTH STATUS PERCEPTIONS Key Findings In 2015, over half (55%) of the Monroe County adults rated their health status as excellent or very good. Conversely, 12% of adults, increasing to 19% of those over the age of 60, described their health as fair or poor. General Health Status In 2015, more than half (55%) of Monroe County adults rated their health as excellent or very good. Monroe County adults with higher incomes (54%) were most likely to rate their health as excellent or very good, compared to 45% of those with incomes less than $25, % of adults rated their health as fair or poor. The 2013 BRFSS has identified that 18% of Michigan and 17% of U.S. adults self-reported their health as fair or poor. Monroe County adults were most likely to rate their health as fair or poor if they: Had been diagnosed with diabetes (37%) Had high blood pressure (24%) or high blood cholesterol (19%) Had an annual household income under $25,000 (22%) Were divorced (21%) Were 60 years of age or older (19%) Physical Health Status In 2015, 21% of Monroe County adults rated their physical health as not good on four or more days in the previous month. Monroe County adults reported their physical health as not good on an average of 3.0 days in the previous month. Michigan and U.S. adults reported their physical health as not good on an average of 3.6 days and 3.7 days, respectively, in the previous month (Source: 2010 BRFSS). Monroe County adults were most likely to rate their physical health as not good if they: Were over the age of 60 (25%) Were female (23%) Mental Health Status Adults Who Rated General Health Status Excellent or Very Good Monroe County 55% (2014) Michigan 51% (2013) U.S. 52% (2013) (Source: BRFSS 2013 for Michigan and U.S.) In 2015, 20% of Monroe County adults rated their mental health as not good on four or more days in the previous month. Monroe County adults reported their mental health as not good on an average of 3.1 days in the previous month. Michigan and U.S. adults reported their mental health as not good on an average of 3.7 days and 3.5 days, respectively in the previous month (Source: 2010 BRFSS). One-in-five (20%) adults reported that poor mental or physical health kept them from doing usual activities such as self-care, work, or recreation. Monroe County adults were most likely to rate their mental health as not good if they: Were ages (26%) Were female (23%) HEALTH PERCEPTIONS 19

22 The following graph shows the percentage of Monroe County adults who described their personal health status as excellent/very good, good, and fair/poor. Examples of how to interpret the information include: 55% of all Monroe County adults, 78% of those under age 30, and 43% of those ages 60 and older rated their health as excellent or very good. The table shows the percentage of adults with poor physical and mental health in the past 30 days. 100% 80% 60% Monroe County Adult Health Perceptions* 0% 12% 11% 14% 13% 22% 19% 22% 33% 36% 31% 36% 38% 33% 10% 36% 40% 78% 20% 55% 53% 55% 51% 43% 45% 54% 0% Total Males Females Under years 60 & Older Income <$25K Excellent/Very Good Good Fair/Poor Income $25K Plus *Respondents were asked: Would you say that in general your health is excellent, very good, good, fair or poor? Health Status No Days 1-3 Days 4-5 Days 6-7 Days 8 or More Days Physical Health Not Good in Past 30 Days* Males 68% 8% 7% 3% 10% Females 60% 8% 7% 4% 12% Total 64% 8% 7% 3% 11% Mental Health Not Good in Past 30 Days* Males 70% 6% 4% 1% 12% Females 56% 9% 4% 0% 14% Total 63% 8% 4% 1% 13% *Totals may not equal 100% as some respondents answered Don t know/not sure. Adult Comparisons Monroe County 2015 Michigan 2013 U.S Rated health as excellent or very good 55% 51% 52% Rated health as fair or poor 12% 18% 17% Average days that physical health not good in past month * 3.7* Average days that mental health not good in past month * 3.5* *2010 BRFSS data 20

23 Adult І HEALTH CARE COVERAGE Key Findings The 2015 Health Assessment data has identified that 9% of Monroe County adults were without health care coverage. Those most likely to be uninsured were adults ages 30-59, those with an income level under $25,000, and females. In Monroe County, 12.9% of residents live below the poverty level. (Source: U.S. Census, American Community Survey 1 Year Estimate, 2013) General Health Coverage In 2015, 91% of Monroe County adults had health care coverage, leaving 9% who were uninsured. The 2013 BRFSS reports uninsured prevalence rates for Michigan (14%) and the U.S. (17%). Monroe County June 2014 Monroe County July 2014 Monroe County Medicaid Health Plan Enrollees Residents Enrolled in Medicaid 16,838 17,529 In the past year, 9% of adults were uninsured, increasing to 12% of those with incomes less than $25,000 and those ages 30-59, and 13% of females. 16% of adults with children did not have healthcare coverage, compared to 6% of those who did not have children living in their household. The following types of health care coverage were used: employer (45%), someone else s employer (16%), multiple-including private sources (12%), Medicaid or medical assistance (9%), Medicare (8%), self-paid plan (4%), multiple-including government sources (3%), Health Insurance Marketplace (1%), military, CHAMPUS, TriCare, or VA (1%), and other (1%). 9% of Monroe County adults were uninsured. Health Plans of Enrollees McLaren Health Plan, Meridian Health Plan of Michigan, Molina Healthcare of Michigan, & United Healthcare Community Plan, Inc. McLaren Health Plan, Meridian Health Plan of Michigan, Molina Healthcare of Michigan, & United Healthcare Community Plan, Inc. (Source: Michigan Department of Community Health, Medicaid Health Plan Enrollees, 2014, from: pdf) Monroe County adult health care coverage includes the following: medical (100%), prescription coverage (95%), immunizations (83%), dental (81%), preventive care (75%), their spouse (73%), outpatient therapy (73%), vision (72%), mental health (71%), their children (62%), County physicians (59%), alcohol and drug treatment (47%), home care (35%), their partner (33%), skilled nursing (31%), long-term care (30%), and hospice (29%). The top reasons uninsured adults gave for being without health care coverage were: 1. They lost their job or changed employers (60%) 2. They could not afford to pay the insurance premiums (16%) 3. They became a part-time or temporary employee (15%) 4. They could not afford to pay the exchange premiums (10%) (Percentages do not equal 100% because respondents could select more than one reason) HEALTH CARE COVERAGE 21

24 The following graph shows the percentages of Monroe County adults who were uninsured by demographic characteristics. Examples of how to interpret the information in the graph includes: 9% of all Monroe County adults were uninsured, 12% of adults with an income less than $25,000 reported being uninsured and 8% of those under age 30 lacked health care coverage. The pie chart shows sources of Monroe County adults health care coverage. 20% Uninsured Monroe County Adults 13% 12% 12% 10% 9% 8% 9% 6% 2% 0% Total Males Females Under years 60 & Older Income <$25K Income $25K Plus 12% of Monroe County adults with incomes less than $25,000 were uninsured. Sources of Health Coverage for Monroe County Adults Medicare 8% Medicaid 9% Self-purchased 4% Other 1% Employer 45% Someone Else's Employer 16% Multiple-Including Private 12% Military 1% Multiple-govt. sources 3% Health Insurance Marketplace 1% Adult Comparisons Monroe County 2015 Michigan 2013 U.S Uninsured 9% 14% 17% 22

25 The following chart shows what is included in Monroe County adults insurance coverage. Health Coverage Includes: Yes No Objective AHS-1.1: Persons under age of 65 years with health care insurance Healthy People 2020 Access to Health Services (AHS) Monroe County % age % age % age % age % age Michigan % age % age % age % age % age U.S % age % age % age % age % age Don t Know Medical 100% 0% <1% Prescription Coverage 95% 3% 1% Immunizations 83% 4% 13% Dental 81% 19% 0% Preventive Health 75% 4% 21% Their Spouse 73% 24% 3% Outpatient Therapy 73% 2% 25% Vision 72% 23% 5% Mental Health 71% 4% 25% Their Children 62% 34% 5% County Physicians 59% 5% 36% Alcohol and Drug Treatment 47% 5% 48% Home Care 35% 10% 55% Their Partner 33% 46% 21% Skilled Nursing 31% 11% 58% Long-term Care 30% 15% 55% Hospice 29% 10% 61% Healthy People 2020 Target 100% *U.S. baseline is age-adjusted to the 2000 population standard (Sources: Healthy People 2020 Objectives, 2013 BRFSS, 2015 Monroe County Health Assessment) HEALTH CARE COVERAGE 23

26 Adult І HEALTH CARE ACCESS AND UTILIZATION Key Findings The 2015 Health Assessment project identified that 64% of Monroe County adults had visited a doctor for a routine checkup in the past year. 63% of adults went outside of Monroe County for health care services in the past year. Health Care Access Monroe County Health Care Statistics In 2014, Monroe County was ranked 35th of 82 Counties in Michigan for Health Outcomes Rank. In 2014, 11% of Monroe County residents could not see a doctor because of cost. In 2014, 11,961 (13%) of all Monroe County residents age 18 to 65 years were uninsured. (Source: Community Health rankings and Roadmaps, Nearly two-thirds (64%) of Monroe County from: ( adults visited a doctor for a routine checkup in the past year, increasing to 76% of those over the age of 60. More than half (57%) of Monroe County adults reported they had one person they thought of as their personal doctor or healthcare provider. 32% of adults had more than one person they thought of as their personal healthcare provider, and 11% did not have one at all. 67% of Monroe County adults reported having a usual source of medical care. Reasons for not having a usual source of medical care included: had two or more usual places (34%), had not needed a doctor (24%), no insurance (7%), cost (6%), did not know where to go (3%), previous doctor unavailable/moved (3%), no place available/close enough (2%), do not like/trust/ believe in doctors (1%), not accepting new patients (1%), and other reasons (7%). 13% of adults reported there was a time in the past year they needed to see a doctor but could not because of cost, increasing to 26% of those with incomes less than $25,000. Monroe County adults did not get medical care for the following reasons: no need to go (10%), cost/no insurance (8%), multiple reasons (2%), office is not open when they could get there (1%), too long of a wait in the waiting room (<1%), distance (<1%), and other reasons (1%). 63% of adults went outside of Monroe County for health care services for the following reasons: better quality program (14%), service not locally available (8%), multiple reasons (8%), used to live there (6%), insurance restriction (5%), word of mouth (3%), bad experience locally (3%), work there (2%), inconvenient hours (1%), confidentiality/anonymity (<1%), and other reasons (14%). Adults usually visited the following places for health care services: doctor s office (70%), urgent care center (3%), Internet (2%), public health clinic or community health department (1%), instore health clinic (1%), chiropractor (1%), hospital emergency room (<1%), and some other kind of place (2%). 18% of adults reported multiple places and 4% had no usual place for health care services. 24

27 Monroe County adults had the following issues regarding their healthcare coverage: deductibles were too high (32%), co-pays were too high (23%), premiums were too high (22%), high HSA account deductible (8%), opted out of certain coverage because they could not afford it (5%), working with their insurance company (5%), could not understand their insurance plan (4%), service not deemed medically necessary (4%), service is no longer covered (3%), pre-existing conditions (3%), limited visits (3%), opted out of certain coverage because they did not need it (2%), and provider is no longer covered (2%). Availability of Services 21% of adults used a program or service to help themselves or a loved one with depression, anxiety, or emotional problems. Reasons for not using a program or service to help with depression, anxiety, or emotional problems included: could not afford to go (6%), had not thought of it (4%), fear (4%), stigma of seeking mental health services (4%), co-pay/deductible was too high (3%), did not know how to find a program (2%), transportation (2%), did not feel the services they had received were good (1%), could not get to the office or clinic (1%), other priorities (1%), and other reasons (3%). 61% of adults indicated this type of program was not needed. Health Care Access and Utilization among Young Adults Aged From January through September 2011, 77.9% of women aged had a usual place for health care compared with 62.5% of men in the same age group. Among adults aged 19 25, those with public health coverage were more likely to have had an emergency room visit in the past 12 months than those with private coverage or the uninsured. In 2011, 57.9% of Hispanic persons aged had a usual place for health care. This was significantly less than non-hispanic white (74.9%) and non-hispanic black (68.4%) persons. In the first 9 months of 2011, adults aged who were poor (67.2%) and those who were near poor (63.0%) were less likely than those who were not poor (76.0%) to have had a usual place for health care. 28% of uninsured adults aged delayed or did not get needed medical care due to cost compared with 7.6% of those with private health insurance and 10.1% of those with public coverage. (Source: CDC, Health Care Access and Utilization among Young Adults Aged 19-25, 2012, Health Care Access among Employed and Unemployed Adults In , 48.1% of unemployed adult s ages years had health insurance compared with 81.4% of employed adults. The unemployed were less likely to receive needed prescriptions due to cost than the employed in all insurance categories. Unemployed adults in were more likely to have fair or poor health than employed adults across all categories of insurance coverage. (Source: CDC, Access to Health Care, 2012, HEALTH CARE ACCESS 25

28 Adult І CARDIOVASCULAR HEALTH Key Findings The 2015 Monroe County Health Assessment found that 6% of adults had survived a heart attack and 3% had survived a stroke at some time in their life. Nearly one-third (32%) of Monroe County adults had been diagnosed with high blood pressure, 35% had high blood cholesterol, 31% were obese, and 14% were smokers, four known risk factors for heart disease and stroke. Heart disease (25%) and stroke (5%) accounted for 30% of all Monroe County adult deaths in 2013 (Source: MDCH, Vital Statistics). Heart Disease and Stroke In 2015, 6% of Monroe County adults reported they had survived a heart attack or myocardial infarction, increasing to 12% of those over the age of 60. 5% of Michigan and 4% of U.S. adults reported they had survived a heart attack or myocardial infarction in 2013 (Source: 2013 BRFSS). Monroe County Leading Types of Death 2013 Total Deaths: 1, Cancer (26% of all deaths) 2. Heart Disease (25%) 3. Chronic Lower Respiratory Diseases (6%) 4. Accidents, Unintentional Injuries (6%) 5. Stroke (5%) (Source: MDCH, Vital Statistics, updated ) Michigan Leading Types of Death 2013 Total Deaths: 92, Heart Disease (26% of all deaths) 2. Cancers (22%) 3. Chronic Lower Respiratory Diseases (6%) 4. Stroke (5%) 5. Accidents, Unintentional Injuries (5%) (Source: MDCH, Vital Statistics, updated ) 3% of Monroe County adults reported they had survived a stroke, increasing to 6% of those over the age of 60. 4% of Michigan and 3% of U.S. adults reported having survived a stroke in 2013 (Source: 2013 BRFSS). 6% of adults reported they had angina or coronary heart disease, increasing to 16% of those over the age of 60. 5% of Michigan and 4% of U.S. adults reported having had angina or coronary heart disease in 2013 (Source: 2013 BRFSS). High Blood Pressure (Hypertension) Nearly one-third (32%) of adults had been diagnosed with high blood pressure. The 2013 BRFSS reports hypertension prevalence rates of 35% for Michigan and 31% for the U.S. 8% of adults were told they were pre-hypertensive/borderline high. 92% of adults had their blood pressure checked within the past year. Monroe County adults diagnosed with high blood pressure were more likely to: o Have rated their overall health as fair or poor (64%) o Have been age 60 years or older (55%) o Have been classified as obese by Body Mass Index-BMI (44%) 26

29 High Blood Cholesterol More than one-third (35%) of adults had been diagnosed with high blood cholesterol. The 2013 BRFSS reported that 41% of Michigan adults and 38% of U.S. adults have been told they have high blood cholesterol. Four-fifths (81%) of adults had their blood cholesterol checked within the past 5 years. The 2013 BRFSS reported 79% of Michigan and 76% of U.S. adults had their blood cholesterol checked within the past 5 years. Monroe County adults with high blood cholesterol were more likely to: o Have been age 60 years or older (61%) o Have rated their overall health as fair or poor (57%) o Have been classified as obese by Body Mass Index-BMI (50%) The following graph demonstrates the percentage of Monroe County adults who had major risk factors for developing cardiovascular disease (CVD). 50% 25% 0% 35% High Blood Cholesterol Monroe County Adults with CVD Risk Factors High Blood Pressure 32% 31% Adult Comparisons (Source: 2015 Monroe County Health Assessment) Monroe County 2015 Michigan 2013 U.S Had angina 6% 5% 4% Had a heart attack 6% 5% 4% Had a stroke 3% 4% 3% Had high blood pressure 32% 35% 31% Had high blood cholesterol 35% 41% 38% Had blood cholesterol checked within past 5 years 24% 14% 13% Obesity Sedentary Smoking Diabetes 81% 79% 76% CARDIOVASCULAR 27

30 The following graphs show the number of Monroe County adults who have been diagnosed with high blood pressure, high blood cholesterol and cardiovascular disease prevalence. Examples of how to interpret the information on the first graph include: 32% of all Monroe County adults have been diagnosed with high blood pressure, 39% of all Monroe County males, 26% of all females, and 55% of those 60 years and older. 80% Diagnosed with High Blood Pressure* 60% 55% 40% 32% 39% 26% 34% 42% 28% 20% 0% 80% 0% Total Male Female Under Years 60 & Older Income <$25K *Does not include respondents who indicated high blood pressure during pregnancy only. Diagnosed with High Blood Cholesterol Income $25K Plus 60% 61% 49% 40% 35% 37% 34% 34% 32% 20% 7% 0% Total Male Female Under Years 60 & Older Income <$25K Income $25K Plus 10% Cardiovascular Disease Prevalence 5% 6% 5% 3% 4% 0% Heart Attack Monroe 2015 Michigan 2013 Stroke (Source: 2015 Monroe Health Assessment and 2013 BRFSS) 28

31 The following graphs show the age-adjusted mortality rates per 100,000 population for heart disease and stroke by gender. When age differences are accounted for, the statistics indicate that the Monroe County heart disease mortality rate was higher than the figure for the state, the U.S. figure and the Healthy People 2020 target. The Monroe County age-adjusted stroke mortality rate for was higher than the state, U.S. figure, and the Healthy People 2020 target objective. Rate per 100,000 population Rate per 100,000 population *The Healthy People 2020 Target objective for Coronary Heart Disease is reported for heart attack mortality. (Source: MDCH, Vital Statistics, updated September 2014, Healthy People 2020) Age-Adjusted Heart Disease and Stroke Mortality Rates Heart Disease Stroke (Source: MDCH, Vital Statistics, updated ) 36.9 Monroe Michigan U.S HP 2020 Target* Monroe County Age-Adjusted Heart Disease Mortality Rates by Gender Monroe Total Monroe Males Monroe Females CARDIOVASCULAR 29

32 The following graph shows the age-adjusted mortality rates per 100,000 population for stroke by gender. Disparities exist for stroke mortality rates by gender in Michigan. The age-adjusted stroke mortality rate has decreased from 2011 to Age-Adjusted Stroke Mortality Rates by Gender Rate per 100,000 population Total Male Female Michigan 2011 Michigan 2012 Michigan 2013 (Source: MDCH, Vital Statistics, 2013) Objective HDS-5: Reduce proportion of adults with hypertension HDS-6: Increase proportion of adults who had their blood cholesterol checked within the preceding 5 years HDS-7: Decrease proportion of adults with high total blood cholesterol (TBC) Healthy People 2020 Objectives Heart Disease and Stroke (HDS) Monroe Survey Population Baseline 32% (2015) 81% (2015) 35% (2015) U.S. Baseline* 31% Adults age 18 and older (2011) 76% Adults age 18 & older (2011) 38% Adults age 20 & older with TBC>240 mg/dl (2011) *All U.S. figures age-adjusted to 2000 population standard. (Source: Healthy People 2020, 2013 BRFSS, 2015 Monroe County Health Assessment) Healthy People 2020 Target 27% 82% 14% 30

33 Stroke Warning Signs and Symptoms F.A.S.T. is an easy way to remember the sudden signs and symptoms of a stroke. When you can spot the signs, you'll know quickly that you need to call for help. This is important because the sooner a stroke victim gets to the hospital, the sooner they'll get treatment. Being prompt can make a remarkable difference in their recovery. F.A.S.T is: Face Drooping: Does one side of the face droop or is it numb? Ask the person to smile. Arm Weakness: Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward? Speech Difficulty: Is speech slurred, are they unable to speak, or are they hard to understand? Ask the person to repeat a simple sentence, like the sky is blue. Is the sentence repeated correctly? Time to call 911: If the person shows any of these symptoms, even if the symptoms go away, call and get them to the hospital immediately. Beyond F.A.S.T- Other Symptoms to Know Sudden confusion or trouble understanding Sudden numbness or weakness of the leg or arm Sudden severe headache with no known cause Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination (Source: American Heart Association, Stroke Warning Signs and Symptoms, 2013, Symptoms_UCM_308528_SubHomePage.jsp) Heart Attack Warning Signs and Symptoms Heart attacks can be sudden and intense, but most start with mild pain or discomfort. Even if you are unsure if it is a heart attack, have it checked out. Here are signs that can indicate a heart attack is happening: Chest discomfort. Most discomfort for heart attacks comes in the center of the chest and lasts for more than a few minutes or goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness or pain. Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, the back, neck, jaw or stomach. Shortness of breath with or without chest discomfort. Other signs may include breaking out in a cold sweat, nausea or lightheadedness. (Source: American Heart Association, Warning Signs of a Heart Attack, 2015, Heart-Attack_UCM_002039_Article.jsp) CARDIOVASCULAR 31

34 Adult І CANCER Key Findings In 2015, 12% of Monroe County adults had been diagnosed with cancer at some time in their life. Michigan Department of Community Health statistics indicate that from , a total of 1,571 Monroe County residents died from cancer, the second leading cause of death in the county. The American Cancer Society advises that not using tobacco products, maintaining a healthy weight, adopting a physically active lifestyle, eating more fruits and vegetables, limiting alcoholic beverages and early detection may reduce overall cancer deaths. Monroe County Incidence of Cancer, 2011 All Types: 642 cases Lung and Bronchus: 114 cases (18%) Prostate: 94 cases (15%) Breast: 89 cases (14%) Colon and Rectum: 53 cases (8%) In 2012, there were 332 cancer deaths in Monroe County. (Source: Michigan Community Health Information Cancer) Adult Cancer 12% of Monroe County adults were diagnosed with cancer at some point in their lives, increasing to 26% of adults over the age of 60. Of those diagnosed with cancer, they reported the following types: other skin cancer (29%), prostate (28%), cervical (24%), melanoma (7%), head and neck (7%), endometrial (4%), colon (4%), breast (4%), bladder (4%), multiple types (4%), thyroid (2%), Hodgkin s lymphoma (2%), and other types of cancer (11%). 12% of Monroe County adults had been diagnosed with cancer at some time in their life. Cancer Facts The Michigan Department of Community Health (MDCH) vital statistics indicate that from , cancers caused 24% (1,571 of 6,586 total deaths) of all Monroe County resident deaths. The largest percent (30%) of cancer deaths were from lung and bronchus cancer (Source: MDCH Vital Statistics). The American Cancer Society reports that smoking tobacco is associated with cancers of the mouth, lips, nasal cavity (nose) and sinuses, larynx (voice box), pharynx (throat), and esophagus (swallowing tube). Also, smoking has been associated with cancers of the lung, colorectal, stomach, pancreas, kidney, bladder, uterine cervix, ovary (mucinous) and acute myeloid leukemia. The 2015 health assessment project has determined that 14% of Monroe County adults were current smokers and many more were exposed to environmental tobacco smoke, also a cause of heart attacks and cancer. Adult Comparisons Monroe County 2015 Michigan 2013 U.S Diagnosed with skin cancer 4%* 5% 6% Diagnosed with any type of cancer, other 8% 8% 7% than skin cancer *Melanoma and other skin cancers are included for diagnosed with skin cancer 32

35 A current smoker is defined as someone who has smoked over 100 cigarettes in their lifetime and currently smokes some or all days. Lung Cancer The Michigan Department of Community Health reports that lung cancer was the second leading cause of male invasive cancer incidence from in Monroe County, with a per year average of 52 cases for males. In Monroe County, 13% of male adults were current smokers and 64% of them had stopped smoking for one or more days in the past 12 months because they were trying to quit (Source: 2015 Monroe County Health Assessment). The Michigan Department of Community Health reports that lung cancer was the second leading cause of female invasive cancer incidence from in Monroe County, with a per year average of 49 cases for females. Approximately 15% of female adults in the county were current smokers and 44% had stopped smoking for one or more days in the past 12 months because they were trying to quit (Source: 2015 Monroe County Health Assessment). According to the American Cancer Society, smoking causes 87% of lung cancer deaths among men and 70% of lung cancer deaths among women in the U.S. The risk of developing lung cancer is about 23 times higher in male smokers and 13 times higher in female smokers, compared to lifelong nonsmokers (Source: American Cancer Society, Facts & Figures 2015). 13% of Monroe County male adults and 15% of female adults were current smokers. Breast Cancer In 2015, 64% of Monroe County females reported having had a clinical breast examination in the past year. 54% of Monroe County females over the age of 40 had a mammogram in the past year. CANCER The 5-year relative survival for women diagnosed with localized breast cancer (cancer that has not spread to lymph nodes or other locations outside the breast) is 99% (Source: American Cancer Society, Facts & Figures 2015). For women in their 20s and 30s, a clinical breast exam should be done at least once every 3 years. Mammograms for women in their 20s and 30s are based upon increased risk (e.g., family history, past breast cancer) and physician recommendation. Otherwise, annual mammography is recommended beginning at age 40 (Source: American Cancer Society, Facts & Figures 2015). 0 More than half (54%) of Monroe County females over the age of 40 had a mammogram in the past year. 33

36 Colon and Rectum Cancer The American Cancer Society recognizes any cancer involving the esophagus, stomach, small intestine, colon, rectum, anus (anal canal and anorectum), liver, gallbladder or pancreas as a digestive cancer. In Monroe County, colorectal cancer was the third leading cause of male and female invasive cancer incidence from 2009 to 2011, with a per year average of 29 new invasive cancer cases for females and 30 for males. The American Cancer Society reports several risk factors for colorectal cancer including: age; personal or family history of colorectal cancer, polyps, or inflammatory bowel disease; obesity; physical inactivity; a diet high in red or processed meat; alcohol use; long-term smoking; and possibly very low intake of fruits and vegetables. In 2015, 79% of Monroe County adults over the age of 50 reported having been screened for colorectal cancers at some time in their life and 61% had been screened in the past 5 years. In the U.S., 90% of colon cancers occur in individuals over the age of 50. Because of this, the American Cancer Society suggests that every person age 50 and older have regular colon cancer screenings. Prostate Cancer In Monroe County, prostate cancer was the leading cause of male invasive cancer incidence from 2009 to 2011, with an average of 74 cases per year. Incidence rates for prostate cancer are 60% higher in African Americans than in whites and they are twice as likely to die of prostate cancer. In addition, about 60% of prostate cancers occur in men over the age of 65, and 97% occur in men 50 and older. Other risk factors include strong familial predisposition, diet high in processed meat or dairy foods, and obesity. African American men and Caribbean men of African descent have the highest documented prostate cancer incidence rates in the world (Source: American Cancer Society, Facts & Figures 2015) Cancer Estimations In 2015, about 1,658,370 new cancer cases are expected to be diagnosed. The World Cancer Research Fund estimates that about one-quarter to one-third of the new cancer cases expected to occur in the U.S. in 2015 will be related to overweight or obesity, physical inactivity, and poor nutrition, and thus could be prevented. About 589,430 Americans are expected to die of cancer in In 2015, about 171,000 cancer deaths will be caused by tobacco use. In Michigan, 57,420 new cases of cancer are expected, and 20,920 cancer deaths are expected. The Michigan female new breast cancer cases are expected to be 7,780. About 8,350 (15%) of all new cancer cases in Michigan are expected to be from lung and bronchus cancers. About 4,190 (7%) of all new cancer cases in Michigan are expected to be from colon and rectum cancers. The Michigan male, new prostate cancer cases are expected to be 8,110 (14%). (Source: American Cancer Society, Facts and Figures 2015, 34

37 Monroe County Number of Cancer Cases Colon & Year All Sites Breast Rectum Lung Prostate Monroe County Number of Cancer Deaths Colon & Year All Sites Breast Rectum Lung Prostate (Source for tables: MDCH, Cancer Statistics updated ) CANCER 35

38 The following graphs show the Monroe County, Michigan and U.S. age-adjusted mortality rates (per 100,000 population, 2000 standard) for all types of cancer in comparison to the Healthy People 2020 objective and cancer as a percentage of total deaths by gender. The graph indicates: When age differences are accounted for, Monroe County had a higher cancer mortality rate than Michigan, the U.S., and the Healthy People 2020 target objective. The percentage of Monroe County males who died from all cancers is higher than the percentage of Monroe County females who died from all cancers. Healthy People 2020 Objective and Age-Adjusted Mortality Rates for All Cancers Rate per 100,000 population Monroe 2012 Michigan 2012 U.S HP 2020 Target (Source: MDCH, Vital Statistics, updated ; Healthy People 2020) Cancer As Percent of Total Deaths in Monroe County by Gender, % 30% 30% 25% 23% 20% 15% 10% 5% 0% Male Female (Source: MDCH, Vital Statistics, updated ) 36

39 Adult І DIABETES Key Findings In 2015, 13% of Monroe County adults had been diagnosed with diabetes. Diabetes The 2015 health assessment project has identified that 13% of Monroe County adults had been diagnosed with diabetes, increasing to 19% of those over the age of 60 and those with incomes less than $25,000. The 2013 BRFSS reports a prevalence of 11% for both Michigan and the U.S. 4% of adults had been diagnosed with pre-diabetes. Adults with diabetes were using the following to treat their diabetes: diabetes pills (77%), checking blood sugar (71%), diet control (63%), checking A1C (51%), exercise (47%), insulin (37%), taking a class (13%), and nothing (6%). Diabetes Facts Nearly 30 million children and adults in the United States have diabetes. 86 million Americans have prediabetes. 1.7 million Americans are diagnosed with diabetes every year. Nearly 10% of the entire U.S. population has diabetes, including over 25% of seniors. As many as 1 in 3 American adults will have diabetes in 2050 if present trends continue. The economic cost of diagnosed diabetes in the U.S. is $245 billion per year. 8.1 million Americans have undiagnosed diabetes Diabetes kills more Americans every year than AIDS and breast cancer combined. Diabetes is the primary cause of death for 69,071 Americans each year, and contributes to the death of 231,051 Americans annually. (Source: American Diabetes Association, 2014 Fast Facts, %20Sean/14_fast_facts_june2014_final3.pdf) More than one-third (37%) of adults with diabetes rated their health as fair or poor. Monroe County adults diagnosed with diabetes also had one or more of the following characteristics or conditions: o 92% were obese or overweight o 73% had been diagnosed with high blood pressure o 71% had been diagnosed with high blood cholesterol DIABETES 30% Monroe County Adults Diagnosed with Diabetes 20% 13% 11% 14% 16% 19% 19% 11% 10% 0% 0% Total Males Females Under Years 60 & Older Income <$25K Income $25K Plus 37

40 Adult Comparisons Monroe County 2015 Michigan 2013 U.S Diagnosed with diabetes 13% 11% 11% Diabetes Symptoms Many people with type 2 diabetes never show any signs, but some people do show symptoms caused by high blood sugar. The most common symptoms of type 2 diabetes are: TYPE 1 DIABETES Frequent urination Unusual thirst Extreme hunger Unusual weight loss Extreme fatigue and irritability TYPE 2 DIABETES Any of the type 1 symptoms Blurred vision Tingling/numbness in hands or feet Recurring skin, gum, or bladder infections Cuts/bruises that are slow to heal Frequent infections (Source: American Diabetes Association, Diabetes Basics, Symptoms, Who is at Greater Risk for Type 2 Diabetes People with impaired glucose tolerance (IGT) and/or impaired fasting glucose (IFG) People over age 45 People with a family history of diabetes People who are overweight or obese People who do not exercise regularly People with low HDL cholesterol or high triglycerides, high blood pressure Certain racial and ethnic groups (e.g. Non-Hispanic Blacks, Hispanic/Latino Americans, Asian Americans and Pacific Islanders, and American Indians and Alaska Natives) Women who had gestational diabetes, or who have had a baby weighing 9 pounds or more at birth (Source: American Diabetes Association, Diabetes Basics, Your Risk: Who is at Greater Risk for Type 2 Diabetes, 38

41 The following graphs show age-adjusted mortality rates from diabetes for Monroe County and Michigan residents with comparison to the Healthy People 2020 target objective. Monroe County s age-adjusted diabetes mortality rate decreased from 2005 to From 2011 to 2013, the Monroe County age-adjusted diabetes mortality rate was higher than the state rate, but less than the national rate and the Healthy People 2020 target objective. Rate per 100,000 population Rate per 100,000 Population Diabetes Age-Adjusted Mortality Rates Monroe Michigan (Source: MDCH, Vital Statistics, updated ) Healthy People 2020 Objectives and Age-adjusted Mortality Rates for Diabetes DIABETES Monroe Michigan U.S HP 2020 Target (Source: MDCH, Vital Statistics, updated and Healthy People 2020, CDC) 39

42 Adult І ASTHMA AND OTHER RESPIRATORY DISEASE Key Findings According to the Monroe County survey data, 17% of adults had been diagnosed with asthma. Asthma and Other Respiratory Disease In 2015, 17% of Monroe County adults had been diagnosed with asthma, increasing to 31% of those under the age of % of Michigan and 14% of U.S. adults had ever been diagnosed with asthma (Source: 2013 BRFSS). There are several important factors that may trigger an asthma attack. Some of these triggers are secondhand smoke, dust mites, outdoor air pollution, cockroach allergens, pets, mold, smoke from burning wood or grass, infections linked to the flu, colds, and respiratory viruses (Source: CDC, 2012). Chronic lower respiratory disease was the 3 rd leading cause of death in Monroe County and in Michigan, in 2012 (Source: MDCH, Vital Statistics). 40% Monroe County Adults Diagnosed with Asthma 31% 30% 20% 17% 15% 19% 16% 15% 12% 19% 10% 0% Total Males Females Under Years 60 & Over Income <$25K Income $25K Plus Adult Comparisons Monroe County 2015 Michigan 2013 U.S Had been diagnosed with asthma 17% 17% 14% 40

43 The following graphs demonstrate the lifetime and current prevalence rates of asthma by gender for Michigan and U.S. residents. Adult Lifetime Asthma Prevalence Rates By Gender Percentage Self-Reported 25% 20% 15% 10% 5% 0% 14.3% Males 11.7% 18.7% Females 16.3% Percentage Self-Reported 20% 15% 10% 5% 0% Asthma Statistics Michigan Lifetime U.S. Lifetime Adult Current Asthma Prevalence Rates By Gender 14.2% 11.3% 8.6% 6.7% Males Females Michigan Current U.S. Current (Source for graphs: 2013 BRFSS) ASTHMA The number of people with asthma continues to grow. One in 12 people (about 25 million, or 8% of the U.S. population) had asthma in 2009, compared with 1 in 14 (about 20 million, or 7%) in From , the prevalence of asthma was higher among children than adults. The prevalence of asthma was higher among multiple-race, black, and American Indian or Alaska Native persons than white persons from Asthma costs the U.S. about $3,300 per person with asthma each year from 2002 to 2007 in medical expenses, missed school and work days, and early deaths. Asthma was linked to 3,447 deaths (about 9 per day) in More than half (53%) of people with asthma had an asthma attack in (Source: American Academy of Allergy, Asthma, and Immunology, Asthma Statistics 2013, from: 41

44 What Causes an Asthma Attack? Tobacco Smoke: People should never smoke near you, in your home, in your car, or wherever you may spend a lot of time if you have asthma. Tobacco smoke is unhealthy for everyone, especially people with asthma. If you have asthma and you smoke, quit smoking. Dust Mites: If you have asthma, dust mites can trigger an asthma attack. To prevent attacks, use mattress covers and pillowcase covers to make a barrier between dust mites and yourself. Do not use down-filled pillows, quilts, or comforters. Remove stuffed animals and clutter from your bedroom. Outdoor Air Pollution: This pollution can come from factories, automobiles, and other sources. Pay attention to air quality forecasts to plan activities when air pollution levels will be low. Cockroach Allergens: Get rid of cockroaches in your home by removing as many water and food sources as you can. Cockroaches are often found where food is eaten and crumbs are left behind. Cockroaches and their droppings can trigger an asthma attack, so vacuum or sweep areas that might attract cockroaches at least every 2 to 3 days. Pets: Furry pets can trigger an asthma attack. If you think a furry pet may be causing attacks, you may want to find the pet another home. If you can t or don t want to find a new home for a pet, keep it out of the person with asthma s bedroom. Mold: Breathing in mold can trigger an asthma attack. Get rid of mold in your home to help control your attacks. Humidity, the amount of moisture in the air, can make mold grow. An air conditioner or dehumidifier will help keep the humidity level low. Smoke from Burning Wood or Grass: Smoke from burning wood or other plants is made up of a mix of harmful gases and small particles. Breathing in too much of this smoke can cause an asthma attack. If you can, avoid burning wood in your home. Other Triggers: Infections linked to influenza (flu), colds, and respiratory syncytial virus (RSV) can trigger an asthma attack. Sinus infections, allergies, breathing in some chemicals, and acid reflux can also trigger attacks. Physical exercise, some medicines, bad weather, breathing in cold air, some foods, and fragrances can also trigger an asthma attack. (Source: Centers for Disease Control, Vital Signs, Asthma, updated November 18, 2014, 42

45 Adult І ARTHRITIS Key Findings According to the Monroe County survey data, 38% of Monroe County adults were diagnosed with arthritis. According to the 2013 BRFSS, 31% of Michigan adults and 25% of U.S. adults were told they have arthritis. Arthritis More than one-third (38%) of Monroe County adults were told by a health professional that they had some form of arthritis, increasing to 61% of those over the age of 60. According to the 2013 BRFSS, 31% of Michigan adults and 25% of U.S. adults were told they have arthritis. 38% of Monroe County adults were told by a health professional that they had some form of arthritis, increasing to 61% of those over the age of 60. An estimated 52.5 million U.S. adults (about 1 of 5) report having doctor-diagnosed arthritis. As the U.S. population ages, the number of adults with arthritis is expected to increase sharply to 67 million by (Source: CDC, Arthritis at a Glance 2014). Adults are at higher risk of developing arthritis if they are female, have genes associated with certain types of arthritis, have an occupation associated with arthritis, are overweight or obese, and/or have joint injuries or infections (Source: CDC). 50% 40% 30% 20% 10% Arthritis Prevalence Increases With Body Weight 16% 20% 29% ARTHRITIS 0% Healthy Weight BMI <25 Overweight BMI Obese BMI >30 (Source for graph: CDC Arthritis, Morbidity and Mortality Weekly Report 2013; 62(44); Adult Comparisons Monroe County 2015 Michigan 2013 U.S Diagnosed with arthritis 38% 31% 25% 43

46 20% of Monroe County adults were limited in some way because of a physical, mental or emotional problem. Among those who were limited in some way, 39% were limited because of arthritis. 70% 60% 50% 40% 30% 20% 10% 0% Arthritis-Attributable Activity Limitations Increase with Weight in the U.S. 38% 37% 45% Healthy Weight Overweight BMI Obese BMI >30 (Source for graph: CDC Arthritis, Morbidity and Mortality Weekly Report 2010; 62(44); Arthritis: Key Public Health Messages Early diagnosis of arthritis and self-management activities can help people decrease their pain, improve function, and stay productive. Key self-management activities include the following: Be Active Research has shown that physical activity decreases pain, improves function, and delays disability. Make sure you get at least 30 minutes of moderate physical activity at least 5 days a week. You can get activity in 10 minute intervals. Watch your weight The prevalence of arthritis increases with increasing weight. Research suggests that maintaining a healthy weight reduces the risk of developing arthritis and may decrease disease progression. A loss of just 11 pounds can decrease the occurrence (incidence) of new knee osteoarthritis and a modest weight loss can help reduce pain and disability. See your doctor Although there is no cure for most types of arthritis, early diagnosis and appropriate management is important, especially for inflammatory types of arthritis. For example, early use of disease-modifying drugs can affect the course of rheumatoid arthritis. If you have symptoms of arthritis, see your doctor and begin appropriate management of your condition. Protect your joints Joint injury can lead to osteoarthritis. People who experience sports or occupational injuries or have jobs with repetitive motions like repeated knee bending have more osteoarthritis. Avoid joint injury to reduce your risk of developing osteoarthritis. (Source: Centers for Disease Control and Prevention, Arthritis: Key Public Health Messages, updated January 2015) 44

47 Adult І WEIGHT STATUS Key Findings The 2015 Health Assessment identified that 73% of Monroe County adults were overweight or obese based on Body Mass Index (BMI). Nearly one-third (31%) of Monroe County adults were obese. The 2013 BRFSS indicates that 32% of Michigan and 29% of U.S. adults were obese by BMI. More than half (53%) of adults were trying to lose weight. Adult Weight Status In 2015, the health assessment indicated that nearly three-fourths (73%) of Monroe County adults were either overweight (42%) or obese (31%) by Body Mass Index (BMI). This puts them at elevated risk for developing a variety of diseases. More than half (53%) of adults were trying to lose weight, 31% were trying to maintain their current weight or keep from gaining weight, and 4% were trying to gain weight. Monroe County adults did the following to lose weight or keep from gaining weight: exercised (56%), ate less food, fewer calories, or foods low in fat (55%), ate a low-carb diet (17%), smoked cigarettes (5%), took diet pills, powders or liquids without a doctor s advice (4%), took prescribed medications (2%), went without eating 24 or more hours (2%), participated in a prescribed dietary or fitness program (2%), took laxatives (1%), used a weight loss program (1%), bariatric surgery (<1%), and vomited after eating (<1%). Physical Activity 31% of Monroe County adults are obese. In Monroe County, 54% of adults were engaging in some type of physical activity or exercise for at least 30 minutes 3 or more days per week. 31% of adults were exercising 5 or more days per week. Nearly one-fourth (24%) of adults were not participating in any physical activity in the past week, including 5% who were unable to exercise. Reasons for not exercising included: time (19%), too tired (18%), weather (17%), laziness (13%), pain/discomfort (13%), chose not to exercise (8%), could not afford a gym membership (5%), no sidewalks (4%), no childcare (3%), no walking/biking trails (3%), safety (2%), did not know what activity to do (2%), no gym available (1%), doctor advised them not to exercise (<1%), and other reasons (4%). The CDC recommends that adults participate in moderate exercise for at least 2 hours and 30 minutes every week or vigorous exercise for at least 1 hour and 15 minutes every week. Whether participating in moderate or vigorous exercise, CDC also recommends musclestrengthening activities that work all major muscle groups on 2 or more days per week (Source: CDC, Physical Activity for Everyone). WEIGHT STATUS On an average day, adults spent time doing the following: 2.7 hours watching television, 1.4 hours on their cell phone 1.2 hours on the computer outside of work,, and 0.3 hours playing video games. More than half (53%) of Monroe County adults were trying to lose weight. 45

48 Nutrition In 2015, 6% of adults were eating 5 or more servings of fruits and vegetables per day. 88% were eating between 1 and 4 servings per day. The American Cancer Society recommends that adults eat at least 2 ½ cups of fruits and vegetables per day to reduce the risk of cancer and to maintain good health. The 2009 BRFSS reported that only 23% of Michigan and U.S. adults were eating the recommended number of servings of fruits and vegetables. Monroe County adults reported the following reasons they chose the types of food they ate: taste (63%), cost (49%), enjoyment (48%), healthiness of food (46%), ease of preparation (41%), availability (39%), time (34%), nutritional content (29%), food they were used to (25%), what their spouse prefers (24%), calorie content (22%), what their child prefers (14%), if the food is organic (11%), if the food is genetically modified (10%), health care provider s advice (5%), and other reasons (2%). Adults reported the following barriers to consuming fruits and vegetables: too expensive (13%), did not like the taste (7%), did not know how to prepare (3%), no variety (2%), transportation (1%), and other barriers (2%). Monroe County adults reported that they ate most of their food at: home (83%), multiple places (12%), work (3%), restaurants (1%), fast food (1%), and other places (<1%). Adults ate out in a restaurant or brought home take-out food an average of 2.2 times per week. Monroe County adults had access to a wellness program through their employer or spouse s employer with the following features: health risk assessment (13%), free/discounted gym membership (12%), lower insurance premiums for participation in wellness program (7%), gift cards or cash for participation in wellness program (7%), on-site fitness facility (6%), on-site health screenings (6%), free/discounted weight loss program (4%), free/discounted smoking cessation program (3%), healthier food options in vending machines or cafeteria (3%), lower insurance premiums for positive changes in health status (3%), on-site health education classes (2%), gift cards or cash for positive changes in health status (1%), and other (2%). 36% of Monroe County adults did not have access to any wellness programs, and 15% had access to more than one wellness program. Obesity Facts More than one-third of U.S. adults (34.9%) are obese. Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer, some of the leading causes of preventable death. The estimated annual medical cost of obesity in the U.S. was $147 billion in 2008 U.S. dollars; the medical costs for people who are obese were $1,429 higher than those of normal weight. Non-Hispanic blacks have the highest age-adjusted rates of obesity (47.8%) followed by Hispanics (42.5%), non-hispanic whites (32.6%), and non-hispanic Asians (10.8%). (Source: CDC, Adult Obesity Facts, updated September 9, 2014, 46

49 The following graphs show the percentage of Monroe County adults who are overweight or obese by Body Mass Index (BMI). Examples of how to interpret the information include: 26% of all Monroe County adults were classified as normal weight, 42% were overweight, and 31% were obese. 100% 80% 60% 40% 20% 0% (Percentages may not equal 100% due to the exclusion of data for those who were classified as underweight) The following graph shows the percentage of Monroe County adults who are obese compared to Michigan and U.S. 60% 40% 20% 0% 31% 28% 42% 53% 26% 19% Monroe County Adult BMI Classifications 33% 32% 34% Total Male Female Under Years 60 & Older Income < $25K (Source: 2015 Monroe County Health Assessment and 2013 BRFSS) Adult Comparisons 8% 50% 35% 37% 39% 23% 24% Monroe County % 47% Normal Overweight Obese 41% 44% 15% Obesity in Monroe County, Michigan, and U.S. Adults 31% 32% Monroe County Michigan U.S. 29% Michigan 2013 Income $25K Plus U.S Obese 31% 32% 29% Overweight 42% 35% 35% 29% 44% 27% WEIGHT STATUS 47

50 Adult І TOBACCO USE Key Findings In 2015, 14% of Monroe County adults were current smokers and 31% were considered former smokers. In 2014, the American Cancer Society (ACS) stated that tobacco use was the most preventable cause of death worldwide, and is responsible for the deaths of approximately half of long-term users. Each year, tobacco use is responsible for almost 6 million premature deaths, 80% of which are in low-and middle-income countries, and by 2030, this number is expected to increase to 8 million. (Source: Cancer Facts & Figures, American Cancer Society, 2015) In 2015, 14% of Monroe County adults were current smokers. Adult Tobacco Use Behaviors The 2015 health assessment identified that one-in-seven (14%) Monroe County adults were current smokers (those who indicated smoking at least 100 cigarettes in their lifetime and currently smoke some or all days). The 2013 BRFSS reported current smoker prevalence rates of 21% for Michigan and 19% for the U.S. Nearly one-third (31%) of adults indicated that they were former smokers (smoked 100 cigarettes in their lifetime and now do not smoke). The 2013 BRFSS reported former smoker prevalence rates of 27% for Michigan and 25% for the U.S. Monroe County adult smokers were more likely to: o Have been divorced (42%) o Have rated their overall health as poor (40%) o Have incomes less than $25,000 (37%) Monroe County adults used the following tobacco products in the past year: cigarettes (20%), e- cigarettes (8%), cigars (6%), hookah (3%), Black and Milds (3%), roll-your-own (2%), chewing tobacco (2%), pipes (2%), little cigars (1%), swishers (1%), cigarillos (1%), and snuff (1%). 52% of current smokers responded that they had stopped smoking for at least one day in the past year because they were trying to quit smoking. 89% of adults reported they believe that secondhand tobacco smoke is harmful to themselves and their family s health. Monroe adults reported they would support an ordinance to ban smoking in the following places: vehicle with a minor present (74%), college/university campuses (57%), parks or ball fields (52%), fairgrounds (47%), and other places (9%). 21% of adults reported they would not support an ordinance to ban smoking anywhere. Adult Comparisons Monroe County 2015 Michigan 2013 U.S Current smoker 14% 21% 19% Former smoker 31% 27% 25% 48

51 The following graph shows the percentage of Monroe County adults who used tobacco. Examples of how to interpret the information include: 14% of all Monroe County adults were current smokers, 31% of all adults were former smokers, and 55% had never smoked. 100% Monroe County Adult Smoking Behaviors 80% 60% 40% 20% 0% 55% 31% 47% 40% 61% 24% 14% 13% 15% 85% 4% 11% 16% 13% Total Male Female Under Years 60 & Older Income <$25K Current smoker Former smoker Never smoked Respondents were asked: Have you smoked at least 100 cigarettes in your entire life? If yes, do you now smoke cigarettes every day, some days or not at all? Income $25K Plus 52% of current smokers responded that they had stopped smoking for at least one day in the past year because they were trying to quit smoking. 53% 31% 47% Smoke-Free Living: Benefits & Milestones 40% 37% According to the American Heart Association and the U.S. Surgeon General, this is how your body starts to recover: In your first 20 minutes after quitting: your blood pressure and heart rate recover from the cigarette-induced spike. After 12 hours of smoke-free living: the carbon monoxide levels in your blood return to normal. After two weeks to three months of smoke-free living: your circulation and lung function begin to improve. After one to nine months of smoke-free living: clear and deeper breathing gradually returns as coughing and shortness of breath diminishes; you regain the ability to cough productively instead of hacking, which cleans your lungs and reduces your risk of infection. One year after quitting smoking, a person s risk of coronary heart disease is reduced by 50 percent. Five to 15 years after quitting smoking, a person s risk of stroke is similar to that of a nonsmoker. After 10 years of smoke-free living, your lung cancer death rate is about half that of a person who has continued to smoke. The risk of other cancers, such as throat, mouth, esophagus, bladder, cervix and pancreas decreases too. (Source: AHA, Smoke-free Living: Benefits & Milestones, 2012, from: Milestones_UCM_322711_Article.jsp) 26% 37% 54% 35% 11% TOBACCO USE 49

52 Electronic Cigarettes Facts Electronic cigarettes (e-cigarettes) are a type of electronic smoking device, resembling cigarettes. They can also look like pipes, pens, or USB memory sticks. E-cigarettes cost approximately $30-60, and refill cartridges cost $7-$10. More recently, disposable e- cigarettes that last up to two packs are being sold for under $10 in local and national convenience stores. Cartridges generally contain mg of nicotine. However, as e-cigarettes are unregulated by the Food and Drug Administration (FDA), their contents and the level of these contents can be highly variable. Ever use of e-cigarettes is highest among current cigarette smoking adults in the U.S. and increased from 9.8% in 2010 to 21.2% in 2011 to 32% in Early studies by the FDA found varying levels of nicotine and other potentially harmful ingredients, including cancer-causing substances and di-ethylene glycol, which is found in anti-freeze. However, these substances were found at much lower levels than in traditional cigarettes. The awareness and use of electronic cigarettes are increasing. In 2011, 6 of 10 U.S. adults were aware of electronic cigarettes with 21% of smokers having ever used an electronic cigarette. Nicotine is found in both inhaled and exhaled vapor of electronic cigarettes. Studies have also found heavy metals, silicates, and cancer-causing compounds in exhaled e-cigarette vapor. (Source: Philadelphia Department of Public Health, Electronic Cigarette Fact sheet, published February 2014, from: & Legacy for Health, Tobacco Fact Sheet, May 2014, from: 31% of Monroe County adults indicated that they were former smokers. The following graph shows Monroe County, Michigan, and U.S. adult cigarette smoking rates. The BRFSS rates shown for Michigan and the U.S. were for adults 18 years and older. This graph shows: Monroe County adult cigarette smoking rate was lower than the Michigan and U.S. rates, and higher than the Healthy People 2020 goal. Healthy People 2020 Objective & Cigarette Smoking Rates 40% 30% 20% 14% 23% 20% 12% 10% 0% Monroe County 2015 Michigan 2012 U.S HP 2020 Target (Source: 2015 Monroe County Health Assessment, 2012 BRFSS and Healthy People 2020) 50

53 The following graphs show Monroe County, Michigan, and U.S. age-adjusted mortality rates per 100,000 population for chronic lower respiratory diseases (formerly COPD) in comparison with the Healthy People 2020 objectives and the percentage of Monroe County and Michigan mothers who smoked during pregnancy. These graphs show: In 2013, Monroe County s age-adjusted mortality rate for Chronic Lower Respiratory Disease was similar to the Michigan rate and lower than the Healthy People 2020 target objective, but higher than the U.S. rate. The 2013 male age-adjusted mortality rate for Chronic Lower Respiratory Disease was higher than the female rate during the same time period. In 2013, the percentage of mothers who smoked during pregnancy in Monroe County was lower than the Michigan rate. Rate per 100,000 population % 40% 30% 20% 46 Age-Adjusted Mortality Rates for Chronic Lower Respiratory Diseases (Formerly COPD) Total Male Female Monroe 2013 Michigan 2013 U.S HP 2020 Target* (Source: MDCH, Vital Statistics and Healthy People 2020) * Healthy People 2020 s target rate and the U.S. rate are for adults aged 45 years and older. **HP2020 does not report different goals by gender. Monroe County and Michigan Births to Mothers Who Smoked During Pregnancy, % 20% TOBACCO USE 10% 0% Monroe Mothers Michigan Mothers (Source: MDCH, Vital Statistics, 2012) 51

54 The following graphs show Monroe County, Michigan, and U.S. age-adjusted mortality rates per 100,000 population for lung cancers in comparison with the Healthy People 2020 objectives and Monroe County incidence rates by gender. These graphs show: In 2012, the Monroe County age-adjusted mortality rate for lung cancer was higher than the state, national, and Healthy People 2020 target objective. Disparities existed by gender for Monroe County lung cancer age-adjusted incidence rates from Rate per 100,000 population Age-Adjusted Mortality Rates for Lung Cancer Monroe 2012 Michigan 2012 U.S HP 2020 Target* (Source: Healthy People 2020, MDCH, updated ) Rate per 100,000 population Age-Adjusted Incidence Rates by Gender for Lung Cancer 67 Monroe Males Monroe Females (Source: MDCH Information updated ) U.S. Adult Smoking Facts The percentage of American adults who smoke decreased from (21%) in 2005 to (18%) in About 1 in 5 (42.1 million) adults still smoke cigarettes. Cigarette smoking is the leading cause of preventable death in the United States, accounting for more than 480,000 deaths, or one of every five deaths, each year. More men (about 21%) than women (about 15%) smoke. More than 16 million Americans suffer from a disease caused by smoking. Adults living below poverty level (29%) are more likely to smoke than adults living at or above poverty level (16%). Smoking rates are higher among people with a lower education level. (Source: CDC, Adult Cigarette Smoking in the United States: Current Estimates, January 23, 2015, from: 52

55 Cigarette Expenditures, Percent of Total Expenditures, National Rank by Census Tract, Nielsen 2014 (Source: Community Commons 5/18/15) TOBACCO USE 53

56 Adult І ALCOHOL CONSUMPTION Key Findings In 2015, the Health Assessment indicated that 12% of Monroe County adults were considered frequent drinkers (drank an average of three or more days per week, per CDC guidelines). 40% of adults who drank had five or more drinks (for males) or 4 or more drinks (for females) on one occasion (binge drinking) in the past month. Four percent of adults drove after having perhaps too much to drink. 54% of Monroe County adults had at least one alcoholic drink in the past month. Adult Alcohol Consumption In 2015, 54% of the Monroe County adults had at least one alcoholic drink in the past month, increasing to 67% of those under the age of 30. The 2013 BRFSS reported current drinker prevalence rates of 57% for Michigan and 55% for the U.S. Approximately one-in-eight (12%) adults were considered frequent drinkers (drank on an average of three or more days per week). Of those who drank, Monroe County adults drank 2.7 drinks on average, increasing to 2.9 drinks for males and those under the age of 30. One-fifth (21%) Monroe County adults were considered binge drinkers. The 2013 BRFSS reported binge drinking rates of 19% for Michigan and 17% for the U.S. 40% of current drinkers reported they had five or more alcoholic drinks (for males) or 4 or more drinks (for females) on an occasion in the last month and would be considered binge drinkers by definition. 4% of adults reported driving after having perhaps too much alcohol to drink. Monroe County adults experienced the following in the past six months: drank more than they expected (6%), spent a lot of time drinking (2%), continued to drink despite problems caused by drinking (2%), tried to quit or cut down but could not (2%), drank more to get the same effect (1%), gave up other activities to drink (1%), failed to fulfill duties at home or work (1%), and drank to ease withdrawal symptoms (1%). 6% of adults used a program or service to help themselves or a loved one with alcohol problems. Reasons for not using a program or service to help with alcohol problems included: had not thought of it (2%), could not afford to go (1%), fear (1%), stigma of seeking alcohol services (<1%), did not want to miss work (<1%), and other reasons (3%). 92% of adults indicated this type of program was not needed. Adult Comparisons Monroe County 2015 Michigan 2013 U.S Drank alcohol at least once in past month 54% 57% 55% Binge drinker (drank 5 or more drinks for males and 4 or more for females on an occasion) 21% 19% 17% 54

57 The following graphs show the percentage of Monroe County adults consuming alcohol and the amount consumed on average. Examples of how to interpret the information shown on the first graph includes: 44% of all Monroe County adults did not drink alcohol, 31% of Monroe County males did not drink, and 55% of adult females reported they did not drink. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percentages may not equal 100% as some respondents answered don t know 12% of Monroe County adults were considered frequent drinkers (drank on an average of three or more days per week) % 16% 44% 18% 31% 14% 55% 30% 26% 13% 44% 12% 48% 17% Total Male Female Under Years 60 & Older Income <$25K 2.7 Average Number of Days Drinking Alcohol in the Past Month 47% 30% 37% 41% 38% Did not drink any 1-2 days 3 or more days 22% 61% 44% 15% 38% Income $25K Plus Adults Average Number of Drinks of Alcohol Consumed Per Drinking Occasion Total Males Females Under Years 60 & Older Income <$25K Income $25K Plus ALCOHOL CONSUMPTION 55

58 The following graphs show the percentage of Monroe County drinkers who binge drank in the past month and a comparison of Monroe County binge drinkers with Michigan and U.S. 60% Monroe County Adult Drinkers Who Binge Drank in Past Month* 52% 40% 40% 41% 40% 43% 46% 40% 27% 20% 0% Total Males Females Under Years 60 & Older Income <$25K Income $25K Plus *Based on adults who have drunk alcohol in the past month. Binge drinking is defined as having five or more drinks (for males) or four or more drinks (for females) on an occasion. Adults must have reported drinking five or more drinks (for males) or four or more drinks (for females) on an occasion at least once in the previous month. 4% of Monroe County adults reported driving after having perhaps too much to drink. 40% Adult Binge Drinkers* 30% 20% 21% 19% 17% 10% 0% Monroe 2015 Michigan 2013 U.S (Source: 2013 BRFSS, 2015 Monroe County Health Assessment) *Based on all adults. Binge drinking is defined as males having five or more drinks on an occasion, females having four or more drinks on one occasion. 56

59 The following table shows the city of Monroe, Monroe County, and Michigan motor vehicle accident statistics. Impaired Driving City of Monroe 2013 Monroe County 2013 (Source: Michigan Office of Highway Safety Planning Crash Reports, 2013 Traffic Crash Facts) Every day, almost 30 people in the United States die in motor vehicle crashes that involve an alcohol-impaired driver. This amounts to one death every 51 minutes. The annual cost of alcohol-related crashes totals more than $59 billion. Michigan 2013 Total Crashes 636 3, ,061 Alcohol-Related Total Crashes ,828 Fatal Crashes Alcohol-Related Fatal Crashes Alcohol Impaired Drivers in Crashes ,828 Injury Crashes ,949 Alcohol-Related Injury Crashes ,765 Property Damage Only 513 3, ,231 Alcohol-Related Property Damage Only ,806 Deaths Alcohol-Related Deaths Total Non-Fatal Injuries ,031 Alcohol-Related Injuries ,242 In 2012, 10,322 people were killed in alcohol-impaired driving crashes, accounting for nearly one-third (31%) of all traffic-related deaths in the United States. Of the 1,168 traffic deaths among children ages 0 to 14 years in 2012, 239 (20%) involved an alcohol-impaired driver. In 2010, over 1.4 million drivers were arrested for driving under the influence of alcohol or narcotics. (Source: CDC, Injury Prevention & Control: Motor Vehicle Safety, January 13, 2015, ALCOHOL CONSUMPTION 57

60 Motor Vehicle Accidents The following graphs show number of Monroe County deaths due to motor vehicle accidents and Monroe County percentage of fatal crashes with drinking involvement. From , there were a total of 86 motor vehicle deaths. Monroe County Number of Motor Vehicle Deaths from N= No. of reported deaths (Source: MTCF, Michigan Traffic Crash Facts) Monroe County Percentage of Fatal Crashes With Drinking Involvement from % 50% 50% 46% 43% 40% 30% 28% 32% 20% 10% 0% (Source: MTCF, Michigan Traffic Crash Facts) 58

61 Alcoholic Beverage Expenditures, Percent of Total Expenditures, National Rank by Census Tract, Nielsen 2011 (Source: Community Commons updated 3/4/15) ALCOHOL CONSUMPTION 59

62 Beer, Wine and Liquor Stores, Rate (Per 100,000 Population) by ZCTA, CBP 2012 ZCTA ZIP Code tabulation area CBP County Business Patterns, U.S. Census Bureau (Source: Community Commons updated 3/4/15) 60

63 Bars and Drinking Establishments, Rate (Per 100,000 Population) by ZCTA, CBP 2012 ZCTA ZIP Code tabulation area CBP County Business Patterns, U.S. Census Bureau (Source: Community Commons updated 3/4/15) ALCOHOL CONSUMPTION 61

64 Adult І DRUG USE Key Findings In 2015, 7% of Monroe County adults had used marijuana during the past 6 months. 11% of adults had used medication not prescribed for them or took more than prescribed to feel good or high and/or more active or alert during the past 6 months. Adult Drug Use 7% of Monroe County adults had used marijuana in the past 6 months, increasing to 15% of those under the age of 30. 2% of Monroe County adults reported using other recreational drugs such as cocaine, synthetic marijuana/k2, heroin, LSD, inhalants, Ecstasy, bath salts, and methamphetamines. When asked about their frequency of marijuana and other recreational drug use in the past six months, 28% of Monroe County adults who used drugs did so almost every day, and 41% did so less than once a month. 11% of adults had used medication not prescribed for them or they took more than prescribed to feel good or high and/or more active or alert during the past 6 months, increasing to 16% of those under the age of 30. When asked about their frequency of medication misuse in the past six months, 23% of Monroe County adults who used these drugs did so almost every day, and 31% did so less than once a month. Monroe County adults obtained these medications from the following: primary care physicians (77%), bought from friend of family member (18%), free from friend or family members (10%), multiple doctors (5%), and ER or urgent care doctor (3%). 4% of Monroe County adults have used a program or service to help with drug problems for either themselves or a loved one. Reasons for not using such a program included: had not thought of it (2%), stigma of seeking drug services (1%), did not want to get in trouble (1%), did not want to miss work (1%), could not afford to go (1%), and other reasons (1%). 94% of adults indicated they did not need a program or service to help with drug problems. Monroe County adults indicated they did the following with their unused prescription medication: took as prescribed (40%), threw it in the trash (22%), kept it (20%), flushed it down the toilet (18%), took it to the Medication Collection program (16%), disposed in RedMed Box, Yellow Jug, etc. (6%), gave it away (1%), sold it (<1%), and some other destruction method (3%). 62

65 The following graphs are data from the 2015 Monroe County Health Assessment indicating adult marijuana use in the past six months and medication misuse in the past six months. Examples of how to interpret the information include: 7% of all Monroe County adults used marijuana in the past six months, 15% of adults under the age of 30 were current users, and 12% of adults with incomes less than $25,000 were current users. 20% Monroe County Adult Marijuana Use in Past 6 Months 15% 15% 12% 10% 5% 0% 20% 15% 10% 5% 7% 9% 11% 11% 6% Monroe County Adult Medication Misuse in Past 6 Months 10% 16% 7% 7% Total Males Females Under Years 60 & Older Income <$25K 11% 6% 12% Income $25K Plus 11% 8% DRUG USE 0% Total Males Females Under Years 60 & Older Income <$25K Income $25K Plus 63

66 Abuse of Prescription (Rx) Drugs Young adults (age 18 to 25) are the biggest abusers of prescription (Rx) opioid pain relievers, ADHD, stimulants, and anti-anxiety drugs. Reasons for abusing these drugs include: getting high, relieving pain, studying better, dealing with problems, losing weight, feeling better, increasing alertness, and having a good time with friends. In 2010, almost 3,000 young adults died from prescription drug (mainly opioid) overdoses. This was a 250% increase from Among young adults, for every death due to Rx drug overdose, there were 17 treatment admissions and 66 emergency room visits. (Source: National Institute on Drug Abuse, Abuse of Prescription (Rx) Drugs Affects Young Adults Most, June 2013, from: Bath Salts Bath salt stimulant products are sold in powder form in small plastic or foil packages of 200 and 500 milligrams under various brand names. Mephedrone is a fine white, off-white, or slightly yellow-colored powder. It can also be found in tablet and capsule form. MDPV is a fine white or off-white powder. Bath salts are usually ingested by sniffing/snorting. They can also be taken orally, smoked, or put into a solution and injected into veins. People who abuse these substances have reported agitation, insomnia, irritability, dizziness, depression, paranoia, delusions, suicidal thoughts, seizures, and panic attacks. Users have also reported effects including impaired perception of reality, reduced motor control, and decreased ability to think clearly. Cathinone derivatives act as central nervous system stimulants causing rapid heart rate (which may lead to heart attacks and strokes), chest pains, nosebleeds, sweating, nausea, and vomiting. (Source: U.S. Department of Justice : DEA Briefs & Background, Drug Fact Sheets, June 2012, from: 64

67 Adult І WOMEN S HEALTH Key Findings In 2015, more than half (54%) of Monroe County women over the age of 40 reported having a mammogram in the past year. 64% of Monroe County women ages 19 and over had a clinical breast exam and 56% had a Pap smear to detect cancer of the cervix in the past year. The Health Assessment determined that 2% of women survived a heart attack and 3% survived a stroke at some time in their life. More than one-quarter (26%) had high blood pressure, 34% had high blood cholesterol, 33% were obese, and 15% were identified as smokers, known risk factors for cardiovascular diseases. Women s Health Screenings In 2015, 71% of women had a (Source: MDCH, updated ) mammogram at some time and more than one-third (37%) had this screening in the past year. More than half (54%) of women ages 40 and over had a mammogram in the past year and 72% had one in the past two years. The 2012 BRFSS reported that 74% of women 40 and over in the U.S. and 77% in Michigan, had a mammogram in the past two years. Most (92%) Monroe County women have had a clinical breast exam at some time in their life and 64% had one within the past year. Three-fourths (76%) of women ages 40 and over had a clinical breast exam in the past two years. The 2010 BRFSS reported that 77% of women 40 and over in the U.S. and 80% in Michigan, had a clinical breast exam in the past two years. This assessment has identified that 96% of Monroe County women have had a Pap smear and 56% reported having had the exam in the past year. 84% of women had a pap smear in the past three years. The 2012 BRFSS indicated that 78% of U.S. and 80% of Michigan women had a pap smear in the past three years. Monroe County women completed an average of 4.3 self-breast exams in the past year, increasing to 4.7 for those ages 40 and older. Pregnancy Monroe County Female Leading Types of Death, Heart Diseases (25% of all deaths) 2. Cancers (23%) 3. Stroke (6%) 4. Chronic Lower Respiratory Diseases (6%) 5. Unintentional Injuries (5%) (Source: MDCH, updated ) Michigan Female Leading Types of Death, Heart Diseases (25% of all deaths) 2. Cancers (21%) 3. Chronic Lower Respiratory Diseases (6%) 4. Stroke (6%) 5. Alzheimer s disease (5%) 32% of Monroe County women had been pregnant in the past 5 years. During their last pregnancy, Monroe County women: got a prenatal appointment in the first 3 months (66%), took a multivitamin (64%), took folic acid during pregnancy (45%), took folic acid pre-pregnancy (39%), experienced perinatal depression (7%), and smoked cigarettes (2%). WOMEN S HEALTH 65

68 Women s Health Concerns In 2013, major cardiovascular diseases (heart disease and stroke) accounted for 31% of all female deaths in Monroe County (Source: MDCH, Vital Statistics). In 2015, the health assessment determined that 2% of women had survived a heart attack and 3% had survived a stroke at some time in their life. Major risk factors for cardiovascular disease include smoking, obesity, high blood cholesterol, high blood pressure, physical inactivity, and diabetes. In Monroe County the 2015 Health Assessment has identified that: 65% were overweight or obese (58% U.S., 61% Michigan, 2013 BRFSS) 34% were diagnosed with high blood cholesterol (37% U.S., 38% Michigan, 2013 BRFSS) 26% were diagnosed with high blood pressure (30% U.S. and 32% Michigan, 2013 BRFSS) 15% of all women were current smokers (17% U.S., 18% Michigan, 2013 BRFSS) 14% had been diagnosed with diabetes (12% U.S., 11% Michigan, 2013 BRFSS) The following graph shows the percentage of Monroe County female adults that had various health exams in the past year. Examples of how to interpret the information shown on the graph includes: 37% of Monroe County females had a mammogram within the past year, 64% had a clinical breast exam, and 56% had a Pap smear. Monroe County Women's Health Exams Within the Past Year 100% 75% 50% 37% 64% 56% 72% 68% 54% 59% 48% 57% 50% 39% 40% 68% 57% 25% 0% 4% Total Under & Older Income <$25K Income >$25K Mammogram Breast Exam Pap Smear Adult Comparisons Had a clinical breast exam in the past two years (age 40 & over) Had a mammogram in the past two years (age 40 & over) Monroe County 2015 Michigan 2013 U.S % 80%* 77%* 72% 77% ** 74% ** Had a pap smear in the past three years 84% 80% ** 78% ** *2010 BRFSS Data ** 2012 BRFSS Data 66

69 The following graphs show the Monroe County and Michigan age-adjusted mortality rates per 100,000 population for cardiovascular diseases. The graphs show: In 2013, the Monroe County and Michigan female age-adjusted mortality rate was lower than the male rate for both heart disease. The Monroe County female heart disease mortality rate was higher than the Michigan female rate in Rate per 100,000 population Rate per 100,000 population Monroe County Age-Adjusted Heart Disease and Stroke Mortality Rates By Gender, Heart Disease Michigan Age-Adjusted Heart Disease and Stroke Mortality Rates By Gender, Heart Disease Stroke (Source for graphs: MDCH, Vital Statistics, updated ) Stroke Male Female Male Female WOMEN S HEALTH 67

70 The following graph shows the Monroe County age-adjusted cancer mortality rates per 100,000 population for women with comparison to Healthy People 2020 objectives when available. The graphs show: From , the Monroe County age-adjusted mortality rate for female lung cancer was higher than the Michigan rate. From , the Monroe County age-adjusted breast cancer mortality rate was less than the Michigan rate but higher than the Healthy People 2020 target objective. 60 Monroe County Female Age-Adjusted Cancer Mortality Rates Rate per 100,000 population Lung Cancer Colon/Rectum Cancer Breast Cancer Monroe Michigan *Note: Healthy People 2020 target rates are not gender specific; Healthy People 2020 Targets may not be available for all diseases. (Source: Michigan Cancer Surveillance Program, updated , and Healthy People 2020) Binge Drinking: A Serious, Under Recognized Problem among Women and Girls Binge drinking for women is defined as consuming 4 or more alcohol drinks (beer, wine, or liquor) on an occasion. Binge drinking is a dangerous behavior but is not widely recognized as a women s health problem. Drinking too much results in about 23,000 deaths in women and girls each year. Binge drinking increases the chances of breast cancer, heart disease, sexually transmitted diseases, unintended pregnancy, and many other health problems. If women binge drink while pregnant, they risk exposing their developing baby to high levels of alcohol, increasing the chances the baby will be harmed by the mother s alcohol use. Drinking alcohol during pregnancy can lead to sudden infant death syndrome and fetal alcohol spectrum disorders. About 1 in 8 women aged 18 years and older and 1 in 5 high school girls binge drink. Women who binge drink do so frequently about 3 times a month and have about 6 drinks per binge. (Sources: Centers for Disease Control and Prevention, Binge Drinking, January 2013, 68

71 Human Papilloma Virus (HPV and Vaccine) Approximately 79 million Americans are infected with human papillomavirus (HPV), and approximately 14 million people will become newly infected each year. Some HPV types can cause cervical, vaginal, and vulvar cancer among women, penile cancer among men, and anal and some oropharyngeal cancers among both men and women. Other HPV types can cause genital warts among both sexes. Each year in the United States an estimated 27,000 new cancers attributable to HPV occur, 17,600 among females (of which 10,400 are cervical cancer) and 9,300 among males (of which 7,200 are oropharyngeal cancers). There are, however, two HPV vaccines available (Gardasil and Cervarix ) which protect against the types of HPV infection that cause most cervical cancers (HPV types 16 and 18). Both vaccines should be given as a three-shot series. Clinical trials and post-licensure monitoring data show that both vaccines are safe. CDC recommends HPV vaccination for the prevention of HPV infections responsible for most types of cervical cancer. (Sources: Centers for Disease Control and Prevention, Vaccine Safety, Human Papillomavirus (HPV) Vaccine, updated January 26, 2015, from Breast Cancer in Young Women Most breast cancers are found in women who are 50 years old or older, but breast cancer also affects younger women. About 11% of all new cases of breast cancer in the United States are found in women younger than 45 years of age. In 2010, 206,966 women and 2,039 men in the United States were diagnosed with breast cancer. 40,996 women and 439 men in the United States died from breast cancer. Some young women are at a higher risk for getting breast cancer at an early age compared with other women their age. If you are a woman under age 45, you may have a higher risk if: You have close relatives (parents, siblings, or children) who were diagnosed with breast or ovarian cancer when they were younger than 45, especially if more than one relative was diagnosed or if a male relative had breast cancer. You have changes in certain breast cancer genes (BRCA1 and BRCA2), or have close relatives with these changes. You were treated with radiation therapy to the breast or chest during childhood or early adulthood. You have been told that you have dense breasts on a mammogram. You have had breast cancer or certain other breast health problems such as lobular carcinoma in situ(lcis), ductal carcinoma in situ (DCIS), atypical ductal hyperplasia, or atypical lobular hyperplasia. You can help lower your risk of breast cancer in the following ways: Get screened for breast cancer regularly. Know how your breasts normally look and feel. Keep a healthy weight. Exercise regularly (at least four hours a week). Breastfeed your babies, if possible. If you plan to have children after 30, talk to your doctor about your cancer risk. Talk to your doctor if you have a family history of breast or ovarian cancer or other risk factors. WOMEN S HEALTH (Source: CDC, Breast Cancer, May 8, 2014, 69

72 Adult І MEN S HEALTH Key Findings In 2015, 60% of Monroe County males over the age of 50 had a Prostate-Specific Antigen (PSA) test. Major cardiovascular diseases (heart disease and stroke) accounted for 28% and cancers accounted for 30% of all male deaths in Monroe County in The Health Assessment determined that 12% of men survived a heart attack and 2% survived a stroke at some time in their life. Nearly two-fifths (39%) of men had been diagnosed with high blood pressure, 37% had high blood cholesterol, and 13% were identified as smokers, which, along with obesity (28%), are known risk factors for cardiovascular diseases. Men s Health Screenings and Concerns More than two-fifths (42%) of Monroe County males had a Prostate-Specific Antigen (PSA) test at some time in their life and 31% had one in the past year. Monroe County Male Leading Causes of Death, Cancers (30% of all deaths) 2. Heart Diseases (24%) 3. Chronic Lower Respiratory Diseases (7%) 4. Accidents, Unintentional Injuries (7%) 5. Diabetes Mellitus (4%) (Source: MDCH, updated ) Michigan Male Leading Types of Death, Heart Diseases (25% of all deaths) 2. Cancers (23%) 3. Chronic Lower Respiratory Diseases (6%) 4. Accidents, Unintentional Injuries (6%) 5. Stroke (4%) (Source: MDCH, updated ) 50% of men had a digital rectal exam in their lifetime and 20% had one in the past year. 79% of males age 50 and over had a PSA test at some time in their life, and 60% had one in the past year. Monroe County males completed an average of 1.0 self-testicular exam in the past year, increasing to 1.4 exams for those ages 50 and older. In 2012, major cardiovascular diseases (heart disease and stroke) accounted for 28% of all male deaths in Monroe County (Source: MDCH, Vital Statistics). In 2015, the health assessment determined that 12% of men had a heart attack and 2% had a stroke at some time in their life. 31% of Monroe County males had a PSA test in the past year. Major risk factors for cardiovascular disease include smoking, obesity, high blood cholesterol, high blood pressure, physical inactivity, and diabetes. In Monroe County the 2015 health assessment has identified that: o 81% were overweight or obese (71% U.S., 71% Michigan, 2013 BRFSS) o 39% were diagnosed with high blood pressure (34% U.S., 37% Michigan, 2013 BRFSS) o 37% were diagnosed with high blood cholesterol (40% U.S., 44% Michigan, 2013 BRFSS) o 13% of all men were current smokers (22% U.S., 25% Michigan, 2013 BRFSS) o 11% had been diagnosed with diabetes (10% U.S., 11% Michigan, 2013 BRFSS) In 2013, cancer was the leading cause of death for Monroe County males (N=206 male resident deaths). Cancer was the second leading cause of death for Michigan males (N=10,647 male resident deaths) (Source: MDCH, Vital Statistics). 70

73 The following graphs show the Monroe County and Michigan age-adjusted mortality rates per 100,000 population for cardiovascular diseases by gender. The graphs show: In 2013, the Monroe County and Michigan male age-adjusted mortality rate was higher than the female rate for heart disease but lower than the female rate for stroke. The Monroe County male age-adjusted heart disease and stroke mortality rates were lower than the Michigan male rates. Monroe County Age-Adjusted Heart Disease and Stroke Mortality Rates By Gender, 2013 Rate per 100,000 population Rate per 100,000 population Heart Disease 165 Stroke Michigan Age-Adjusted Heart Disease and Stroke Mortality Rates By Gender, Heart Disease 160 (Source for graphs: MDCH, Vital Statistics, updated ) Stroke Male Female Male Female MEN S HEALTH 71

74 The following graph shows the Monroe County age-adjusted cancer mortality rates per 100,000 population for men with comparison to Healthy People 2020 objective. The graph shows: From , the Monroe County age-adjusted mortality rate for male lung cancer was higher than the Michigan rate. The age-adjusted prostate cancer mortality rate in Monroe County for was lower than the Michigan rate and the Healthy People 2020 objective. 100 Monroe County Male Age-Adjusted Cancer Mortality Rates Rate per 100,000 population Lung Cancer Colon/Rectum Cancer Prostate Cancer Monroe Michigan HP 2020 Target* *Note: the Healthy People 2020 target rates are not gender specific. (Source: Michigan Cancer Surveillance Program, updated , and Healthy People 2020) Adult Comparisons Had a PSA test within the past two years (age 40 & over) Monroe County 2015 Michigan 2013 U.S % 48%* 45%* *2012 BRFSS data Men s Health Data Approximately 12% of adult males aged 18 years or older reported fair or poor health. 21% of adult males in the U.S. currently smoke. Of the adult males in the U.S., 31% had 5 or more drinks in 1 day at least once in the past year. Only 54% of adult males in the U.S. met the 2008 federal physical activity guidelines for aerobic activity through leisure-time aerobic activity. 35% of men 20 years and over are obese. There are 19% of males under the age of 65 without health care coverage. The leading causes of death for males in the United States are heart disease, cancer and accidents (unintentional injuries). (Source: CDC, National Center for Health Statistics, Men s Health, Fast Stats, 2/6/2015 from 72

75 Cancer and Men Every year, cancer claims the lives of nearly 300,000 men in America. More men in the U.S. die from lung cancer than any other type of cancer. The most important thing you can do to prevent lung cancer is not to start smoking, or to quit if you smoke. Smoking causes cancers of the esophagus, larynx (voice box), mouth, throat, kidney, bladder, pancreas, stomach, and acute myeloid leukemia. In men, the following cancers are associated with being overweight: colorectal cancer, esophageal adenocarcinoma (a type of cancer of the tube that connects your throat to your stomach), and cancer of the kidney and pancreas. Prostate cancer is the most common cancer in men in the U.S., not counting skin cancer. It is the second most common cause of cancer death in men. While all men are at risk for prostate cancer, some factors increase risk. These include: o older age o family history of prostate cancer o being African American Colorectal cancer is the third leading cause of cancer deaths in America men. Screening tests can find precancerous polyps so they can be removed before they turn into cancer. Everyone should be tested for colorectal cancer regularly, starting at age 50. (Source: Center for Disease Control and Prevention, National Cancer Institute, May 28, 2014, Heart Health and Stroke Facts for Men Heart disease is the leading cause of death for men in the United States, killing 307,225 men in 2009 that s 1 in every 4 male deaths. Heart disease is the leading cause of death for men of most racial/ethnic groups in the United States, including African Americans, American Indians or Alaska Natives, Hispanics, and whites. For Asian American or Pacific Islander men, heart disease is second only to cancer. About 8.5% of all white men, 7.9% of black men, and 6.3% of Mexican American men have coronary heart disease. Half of the men who die suddenly of coronary heart disease have no previous symptoms. Even if you have no symptoms, you may still be at risk for heart disease. Between 70% and 89% of sudden cardiac events occur in men High blood pressure, high LDL cholesterol, and smoking are key risk factors for heart disease. About half of Americans (49%) have at least one of these three risk factors. Several other medical conditions and lifestyle choices can also put people at higher risk for heart disease, including: Diabetes Physical inactivity Excessive Alcohol Use Poor diet Overweight and obesity (Source: CDC, Men and Heart Disease Fact Sheet, updated , from: MEN S HEALTH 73

76 Adult І PREVENTIVE MEDICINE AND HEALTH SCREENINGS Key Findings More than half (55%) of adults ages 65 and older had a pneumonia vaccination at some time in their life. Three-fifths (61%) of adults ages 50 and older had a colonoscopy/sigmoidoscopy within the past 5 years. Preventive Medicine Nearly half (45%) of Monroe County adults had a flu vaccine during the past 12 months. Of those who had a flu vaccine, 99% had the shot and 1% had the nasal spray. (Source: CDC, Immunization Schedules, updated 9-18, 76% of Monroe County adults ages 65 and 2014, older had a flu vaccine in the past 12 months. The 2013 BRFSS reported that 63% of U.S. and 57% of Michigan adults ages 65 and older had a flu vaccine in the past year. More than one-fifth (22%) of adults have had a pneumonia shot in their life, increasing to 55% of those ages 65 and older. The 2013 BRFSS reported that 70% of U.S. and 69% of Michigan adults ages 65 and older had a pneumonia shot in their life. Monroe County adults have had the following vaccines: tetanus booster (including Tdap) in the past 10 years (53%), pneumonia vaccine in their lifetime (22%), pertussis vaccine in the past 10 years (14%), Zoster (shingles) vaccine in their lifetime (7%), and human papillomavirus vaccine in their lifetime (5%). Preventive Health Screenings and Exams Reasons Some Adults Still Need Vaccines Some adults incorrectly assume that the vaccines they received as children will protect them for the rest of their lives. Generally this is true, except that: Some adults were never vaccinated as children. Newer vaccines were not available when some adults were children. Immunity can begin to fade over time. As we age, we become more susceptible to serious disease caused by common infections (such as flu and pneumococcus). Three-fifths (61%) of adults ages 50 and older had a colonoscopy or sigmoidoscopy in the past 5 years. Adults reported they were at risk of developing the following based on family history: high blood pressure (56%), heart disease (47%), cancer (46%), diabetes (38%), high blood cholesterol (32%), alcohol addiction (14%), Alzheimer s disease (13%), mental illness (11%), drug addiction (5%), and unexplained sudden death (1%). 37% of adults have been screened by a doctor or other health professional for skin cancer. In the past year, 54% of Monroe County women ages 40 and older have had a mammogram. In the past year, 60% of Monroe County men ages 50 and older have had a PSA test. See the Women and Men s Health Sections for further prostate, mammogram, clinical breast exam, and Pap smear screening test information for Monroe County adults. 74

77 Adult Comparisons Had a pneumonia vaccination (ages 65 and older) Had a flu vaccine in the past year (ages 65 and older) Monroe County Adult Health Screening Results GENERAL SCREENING RESULTS Total Sample Diagnosed with High Blood Cholesterol 35% Diagnosed with High Blood Pressure 32% Diagnosed with Diabetes 13% Diagnosed with a Heart Attack 6% Diagnosed with a Stroke 3% Healthy People 2020 Immunization and Infectious Diseases (IID) - Pneumonia Vaccination Objective IID-13.1: Increase the percentage of non-institutionalized high-risk adults aged 65 years and older who are vaccinated against pneumococcal disease Monroe County 2015 Who Should Get a Yearly Flu Shot? Michigan 2013 U.S % 69% 70% 76% 57% 63% (Percentages based on all Monroe County adults surveyed) Monroe County 2015 Michigan 2013 U.S Healthy People 2020 Target 55% 69% 70% 90% *U.S. baseline is age-adjusted to the 2000 population standard (Sources: Healthy People 2020 Objectives, 2013 BRFSS, 2015 Monroe County Health Assessment) The following groups are recommended to get a yearly flu vaccine: All persons aged 6 months and older should be vaccinated annually. When vaccine supply is limited, vaccination efforts should focus on delivering vaccination to persons who: Are aged 6 months through 4 years. Are aged 50 years and older. Have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, neurologic, hematologic, or metabolic disorders (including diabetes mellitus). Are or will be pregnant during the influenza season. Are American Indians/Alaska Natives. Are morbidly obese (body-mass index is 40 or greater. Are health-care personnel. Are household contacts and caregivers of children aged younger than 5 years and adults aged 50 years and older, with particular emphasis on vaccinating contacts of children aged younger than 6 months. Are household contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza. (Source: CDC, Seasonal Influenza (Flu), Who Should Get Vaccinated Against Influenza, Updated in 2014, from: PREVENTIVE MEDICINE 75

78 Environmental Health Monroe County adults indicated the following as their main method or way of getting information from authorities in a large-scale disaster or emergency: television (73%), radio (48%), Internet (46%), Monroe County Emergency Alert System (37%), friends/family (35%), social media (28%), neighbors (26%), newspaper (14%), and other methods (2%). Monroe County households had the following disaster preparedness supplies: cell phone (88%), working flashlight and working batteries (87%), cell phone with texting (80%), 3-day supply of nonperishable food for everyone in the household (60%), 3-day supply of prescription medications for each person who takes prescribed medicines (56%), home land-line telephone (54%), working battery-operated radio and working batteries (51%), generator (48%), 3-day supply of water for everyone in the household (1 gallon of water per person per day) (47%), communication plan (22%), plan for their pets (14%), and a disaster plan (10%). 30% of Monroe County adults had a private water source for drinking water. Of those who had a private water source, 9% had it tested within the past year, and 17% have never had it tested. 31% did not know the last time their water source had been tested. Monroe County adults thought the following threatened their health in the past year: Insects (11%) Radon (1%) Unsafe water supply/wells (6%) Safety hazards (1%) Mold (5%) General living conditions (1%) Temperature regulation (4%) Sewage/waste water problems (1%) Rodents (4%) Bed bugs (1%) Plumbing problems (3%) Excess medications in the home (1%) Lead paint (1%) Lice (1%) Chemicals found in products (1%) Cockroaches (<1%) 76

79 Adult І SEXUAL BEHAVIOR AND PREGNANCY OUTCOMES Key Findings In 2015, over two-thirds (70%) of Monroe County adults had sexual intercourse. Six percent of adults had more than one partner. Prevalence estimates suggest that young people aged years acquire half of all new STDs and that 1 in 4 sexually active adolescent females have an STD, such as chlamydia or human papillomavirus (HPV) (Source: CDC, STDs in Adolescents and Young Adults, 2014 STD Surveillance). Adult Sexual Behavior Over two-thirds (70%) of Monroe County adults had sexual intercourse in the past year. 6% of adults reported they had intercourse with more than one partner in the past year, increasing to 17% of those with incomes less than $25,000 and 22% of those under the age of 30. Monroe County adults used the following methods of birth control: vasectomy (27%), they or their partner were too old (18%), hysterectomy (18%), tubes tied (16%), condoms (11%), birth control pill (11%), withdrawal (6%), abstinence (3%), IUD (2%), rhythm method (2%), infertility (2%), diaphragm (1%), and contraceptive patch (<1%). 12% of Monroe County adults were not using any method of birth control. Monroe County adults did not use birth control for the following reasons: They or their partner had a hysterectomy/vasectomy/tubes tied (40%) They or their partner were too old (22%) They wanted to get pregnant (7%) They did not think they or their partner could get pregnant (6%) They did not want to use birth control (4%) They did not care if they or their partner got pregnant (3%) No regular partner (3%) They or their partner did not like birth control/fear of side effects (1%) They or their partner were currently breastfeeding (1%) Their partner did not want to use birth control (1%) They had a same-sex partner (1%) They could not pay for birth control (<1%) Religious preferences (<1%) The following situations applied to Monroe County adults in the past year: had sex with someone they did not know (3%), tested for an STD (3%), had anal sex without a condom (2%), treated for an STD (1%), and used intravenous drugs (<1%). Adults indicated that HIV is transmitted in the following ways: unprotected sex (94%), sharing needles (94%), and infected blood (91%). 4% of adults did not know how HIV is transmitted. SEXUAL BEHAVIOR 77

80 The following graph shows the sexual activity of Monroe County adults. Examples of how to interpret the information in the graph include: 64% of all Monroe County adults had one sexual partner in the last 12 months and 6% had more than one, and 59% of males had one partner in the past year. Number of Sexual Partners in the Past Year 100% 80% 60% 40% 20% 30% 33% 6% 8% 64% 59% 28% 4% 67% 37% 22% 41% 22% 5% 73% 53% 53% 1% 17% 47% 30% 24% 5% 71% 0% Total Male Female Under Years 60 & Older Income <$25K One More than one None Income $25K Plus Respondents were asked: During the past 12 months, with how many different people have you had sexual intercourse? HIV in the United States More than 1.2 million people in the United States are living with HIV infection, and almost 1 in 7 (14%) are unaware of their infection. By race, African Americans face the most severe burden of HIV. The estimated incidence of HIV has remained stable overall in recent years, at about 50,000 new HIV infections per year. In 2012, an estimated 47,989 people were diagnosed with HIV infection in the United States. In that same year, an estimated 27,928 people were diagnosed with AIDS. Since the epidemic began, an estimated 1,170,989 people in the United States have been diagnosed with AIDS An estimated 13,834 people with an AIDS diagnosis died in 2011, and approximately 648,459 people in the United States with an AIDS diagnosis have died since the epidemic. (Source: CDC, HIV in the United States: At a Glance, 11/25/14, from: 78

81 The following graphs show Monroe County chlamydia disease rates per 100,000 population updated June 24, 2013 by the Michigan Department of Community Health. The graphs show: Monroe County chlamydia rates fluctuated from 2009 to 2013, but increased overall. Monroe County rates remained below the Michigan rates. In 2013, the U.S. rate for new chlamydia cases was per 100,000 population (Source: CDC, Reported STDs in the U.S., 2013). Rate per 100,000 Population Number of cases reported Chlamydia Annualized Disease Rates for Monroe County and Michigan (Source for graph: Michigan Sexually Transmitted Diseases, Updated ) Monroe 352 Michigan Annualized Count of Chlamydia Cases for Monroe County (Source for graph: Michigan Sexually Transmitted Diseases, Updated ) SEXUAL BEHAVIOR 79

82 The following graphs show Monroe County gonorrhea disease rates per 100,000 population updated June 20, 2013 by the Michigan Department of Community Health. The graphs show: The Monroe County gonorrhea rate increased from 2008 to The Michigan gonorrhea rate decreased from 2009 to In 2013, the U.S. rate for new gonorrhea cases for the total population was per 100,000 population (Source: CDC, Reported STDs in the U.S., 2013). The Healthy People 2020 objective for gonorrhea is 257 new female and 198 new male cases per 100,000 population. Rate per 100,000 population Gonorrhea Annualized Disease Rates for Monroe County and Michigan Monroe Michigan Number of cases reported Monroe County Gonorrhea Cases, Both Sexes, by Age & Over (Source for graphs: Michigan Sexually Transmitted Diseases, Updated ) 80

83 Pregnancy Outcomes *Please note that the pregnancy outcomes data includes all births to adults and adolescents. In 2013, the U.S. fertility rate was 62.5 per 1,000 women ages (Source: CDC, Births and Natality, 2013). From , there was an average of 1,595 live births per year in Monroe County. In 2013, there were a total of 1,520 live births in Monroe County. Number of Live Births Rate per 1,000 Population 2,000 1,500 1, Monroe County and Michigan Crude Birth Rates Monroe Michigan 1,731 Monroe County Total Live Births 1,597 1,596 1,530 1, (Source for graphs: Michigan Department of Community Health, Natality and Pregnancy, Updated ) SEXUAL BEHAVIOR 81

84 The following graphs show Monroe County total number of live births by age of the mother and Monroe County and infant mortality rates updated January 14, 2015 by the Michigan Department of Community Health. The graphs show: In 2013, more than half (58%) of live births in Monroe County were to mothers between years old. In 2013, the Monroe County infant mortality rate was higher than the state rate. Monroe County Live Births by Age of Mother in Number t of Live Births Monroe County Infant Mortality Rates, * 20 Rate per 1,000 Population Monroe Michigan *Deaths occurring to individuals less than 1 year of age. *The infant death rate is the number of resident infant deaths divided by total resident live births X 1,000 *A rate could not be calculated for Monroe County in 2011 because the data was small. (Source for graphs: Michigan Department of Community Health, Natality and Pregnancy, Updated ) 82

85 The following graphs show Monroe County and Michigan abortion rates and low birth weight rates updated January 14, 2015 by the Michigan Department of Community Health. The graphs show: From , Monroe County abortion rates fluctuated, but remained well below the Michigan rates for the same period. From , the low birth weight rates for Monroe County were below the Michigan rates. In 2013, 8.0% of all U.S. live births were low birth weight births. (Source: CDC, Birthweight and Gestation, 2013) Rate per 1,000 Population Percent of Live Births % 12% 10% 8% 6% 4% 2% 0% 5.7 Abortion Rates by County and State for Females, ages Monroe Michigan Monroe County and Michigan Low Birth Weight Births* 8.4% 8.4% 8.0% 8.4% 8.5% 8.3% 7.7% 7.1% 6.7% 7.0% Monroe Michigan *Low Birth Weight is defined as weighing less than 2,500 grams or 5 pounds, 8 ounces. (Source for graphs: Michigan Department of Community Health, Natality and Pregnancy, Updated ) SEXUAL BEHAVIOR 83

86 Adult І QUALITY OF LIFE Key Findings In 2015, 20% of Monroe County adults were limited in some way because of a physical, mental or emotional problem. Impairments and Health Problems In 2015, one-fifth (20%) of Monroe County adults were limited in some way because of a physical, mental or emotional problem (23% for Michigan and 20% for the U.S., 2013 BRFSS), increasing to 29% of those with incomes less than $25,000 and those ages 60 and older. Preventing High Blood Pressure: Healthy Living Habits By living a healthy lifestyle, you can help keep your blood pressure in a healthy range and lower your risk for heart disease and stroke. A healthy lifestyle includes: Eating a healthy diet Maintaining a healthy weight Getting enough physical activity Not smoking Limiting alcohol use (Source: CDC, High Blood Pressure, July , from: Among those who were limited in some way, the following most limiting problems or impairments were reported: back or neck problems (44%), arthritis/rheumatism (39%), chronic pain (36%), stress, depression, anxiety, or emotional problems (33%), sleep problems (27%), walking problems (21%), high blood pressure (15%), heart problems (15%), lung/breathing problems (14%), mental health illness/disorder (11%), diabetes (11%), fractures, bone/joint injuries (9%), hearing problems (9%), eye/vision problems (8%), other mental health issues (7%), tobacco dependency (5%), stroke-related problems (2%), incontinence (2%), a learning disability (2%), drug addiction (1%), a developmental disability (1%), cancer (1%), and alcohol dependency (1%). Monroe County adults needed help with the following because of an impairment or health problem: household chores (8%), shopping (6%), transportation (5%), doing necessary business (4%), dressing (2%), getting around for other purposes (1%), bathing (1%), eating (1%), and child care (1%). Monroe County adults were responsible for providing regular care or assistance to the following: multiple children (20%), an elderly parent or loved one (10%), a friend, family member or spouse who has a health problem (9%), someone with special needs (5%), a friend, family member or spouse with a mental health issue (5%), an adult child (4%), grandchildren (4%), children with discipline issues (3%), and a friend, family member or spouse with dementia (2%). Adult Comparisons Limited in some way because of a physical, mental, or emotional problem Monroe County 2015 Michigan 2013 U.S % 23% 20% 84

87 The following graphs show the percentage of Monroe County adults that were limited in some way and the most limiting health problems. Examples of how to interpret the information shown on the graph include: 20% of Monroe County adults are limited in some way, 24% of males, and 29% of those 60 and older. 40% 30% 20% 10% 60% 50% 40% 30% 20% 10% 0% 0% 20% 24% Monroe County Adults Limited in Some Way 16% 11% 21% 29% 29% Total Male Female Under Years 60 & Older Income <$25K 44% Back and Neck Problems Monroe County Most Limiting Health Problems 39% Arthritis/ Rheumatism 36% Chronic Pain 33% Stress, Depression, Anxiety, Emotional Problems 27% Sleep Problems 19% Income $25K Plus 21% Walking Problems QUALITY OF LIFE 85

88 Healthy People 2020 Arthritis, Osteoporosis, and Chronic Back Conditions (AOCBC) Objective Monroe County 2015 Healthy People 2020 Target AOCBC-2: Reduce the proportion of adults with doctor-diagnosed arthritis who experience a limitation in activity due to arthritis or joint symptoms 39% 36% *U.S. baseline is age-adjusted to the 2000 population standard (Sources: Health People 2020 Objectives, 2015 Monroe County Health Assessment) Physical Activity among Adults with Disabilities More than 21 million adults in the United States have a disability. These are adults with difficulty walking or climbing stairs, hearing, seeing, or concentrating, remembering, or making decisions. Adults with disabilities are three times more likely to have heart disease, stroke, diabetes, or cancer than adults without disabilities. Aerobic physical activity can help reduce the impact of these chronic diseases, yet nearly half of all adults with disabilities get no leisure time aerobic physical activity. Adults with disabilities were 82% more likely to be physically active if their doctor recommended it. However, only 44% of adults with disabilities who visited a doctor in the past year received a physical activity recommendation from their doctor. Doctors and other health professionals should recommend physical activity, based on the 2008 Physical Activity Guidelines, to their patients with disabilities. Adults with disabilities should consider the following when engaging in physical activity: Engage in the amount and types of physical activity that are right for them. Find opportunities to increase regular physical activity in ways that meet their needs and abilities. Start slowly based on their abilities and fitness level. Avoid being physically inactive. Know that most aerobic physical activity may need to be modified, adapted or may need additional assistance or equipment. (Source: CDC, Increasing Physical Activity among Adults with Disabilities, 2014, 86

89 Adult І SOCIAL CONTEXT AND SAFETY Key Findings In 2015, 9% of Monroe County adults were threatened or abused in the past year. 50% of adults kept a firearm in or around their home. Social Context 9% of Monroe County adults were threatened or abused in the past year. They were threatened by the following: someone outside their home (56%), a spouse or partner (13%), a child (9%), a parent (9%), and someone else (16%). Monroe County adults received assistance for the following in the past year: food (11%), prescription assistance (8%), mental illness issues (6%), utilities (5%), employment (4%), rent/mortgage (4%), legal aid services (3%), free tax preparation (2%), home repair (2%), alcohol or other substance dependency (1%), transportation (1%), credit counseling (1%), clothing (1%), emergency shelter (1%), unplanned pregnancy (1%), abuse or neglect issues (1%), homelessness (<1%), and post-incarceration transition issues (<1%). 3% of adults reported they went to bed hungry at least one day per week because they could not afford food, increasing to 6% of those with incomes less than $25,000 and 7% of those under the age of 30. Less than 1% went to bed hungry every day of the week. Monroe County adults experienced the following as a child: lived with someone who was a problem drinker or alcoholic (24%), their parents became separated or were divorced (23%), a parent or adult in their home swore at, insulted, or put them down (16%), lived with someone who was depressed, mentally ill, or suicidal (13%), their parents or adults in their home slapped, hit, kicked, punched, or beat each other up (13%), a parent or adult in their home hit, beat, kicked, or physically hurt them (10%), someone at least 5 years older than them or an adult touched them sexually (8%), lived with someone who used illegal street drugs, or who abused prescription medications (6%), someone at least 5 years older than them or an adult tried to make them touch them sexually (5%), lived with someone who served time or was sentenced to serve time in prison, jail or other correctional facility (4%), someone at least 5 years older than them or an adult forced them to have sex (2%), and their parents were not married (1%). Safety 9% of Monroe County adults were threatened or abused in the past year. Monroe County residents reported the following concerns about their community: drug abuse (52%), unemployment (39%), distracted driving (33%), youth substance abuse (33%), violence (32%), opiate/prescription drug abuse (30%), bullying (29%), school funding (28%), homelessness (26%), lack of affordable healthcare (25%), senior/elder care (24%), traffic (24%), DUI (21%), alcohol use/abuse (21%), underemployment (20%), lack of physical activity (19%), parents hosting/allowing underage drinking (18%), speeding (18%), teenage pregnancy (17%), lack of nutrition and healthy eating (16%), lack of affordable housing (13%), suicide prevention (13%), sexting (13%), tobacco use (12%), lack of health education (11%), lack of knowledge about healthy cooking (10%), bicycle safety (9%), lack of affordable transportation (8%), discrimination based on race, ethnicity or sexual orientation (8%), child care availability (7%), cancer prevention screening (6%), disaster preparedness (6%), chronic disease prevention (6%), seat belt or restraint usage (6%), falls (4%), and gambling (3%). SOCIAL CONTEXT 87

90 Half (50%) of Monroe County adults kept a firearm in or around their home. 5% of adults reported they were unlocked and loaded. Monroe County adults reported doing the following while driving: wearing a seatbelt (95%), talking on hand-held cell phone (46%), eating (40%), talking on hands-free cell phone (32%), texting (11%), using internet on their cell phone (6%), checking facebook on their cell phone (4%), being under the influence of alcohol (3%), being under the influence of drugs (2%), reading (1%), and other activities (such as applying makeup, shaving, etc.) (3%). Distracted Driving Distracted driving is driving while doing another activity that takes your attention away from driving. Distracted driving can increase the chance of a motor vehicle crash. Each day, more than 9 people are killed and more than 1,153 people are injured in crashes that were reported to involve a distracted driver. In 2012, 3,328 people were killed in crashes involving a distracted driver. An additional 421,000 people were injured in motor vehicle crashes involving a distracted driver in % of drivers in the U.S. ages reported that they had talked on their cell phone while driving, and 31% reported that they had read or sent text messages or messages while driving at least once within the last 30 days. Nearly half of all U.S. high school students aged 16 years or older text or while driving. (Source: CDC, Distracted Driving, updated October10, 2014, Veterans Affairs 14% of adults reported they or an immediate family member served in the military in the past years. As a result of this military service, the following have affected veterans immediate family members: had problems getting VA benefits (13%), access to medical care at a VA facility (11%), posttraumatic stress disorder (PTSD) (11%), major health problems due to injury (9%), access to medical care at a non-va facility (6%), access to mental health treatment (6%), substance/drug abuse (6%), had problems getting information on VA eligibility and applying (4%), and could not find/keep a job (2%). 75% did not have any problems listed. 88

91 The following graph shows the percentage of Monroe County adults that had a firearm in the home. Examples of how to interpret the information shown on the first graph include: 50% of all Monroe County adults kept a firearm in their home, 57% of males, and 51% of those ages kept a firearm in their home. 75% 50% 25% 0% Victims of Gun Violence in America More than 100,000 people are shot in murders, assaults, suicides and suicide attempts, accidents or by police intervention in America in an average year. o 31,537 people die from gun violence and 71,386 people survive gun injuries. Every day, an average of 282 people are shot in America. Of those 282 people, 86 people die and 196 are wounded, but survive. o Of the 282 people who are shot every day, an average of 50 are children and teens. o Of the 86 people who die, 32 are murdered, 51 are suicides, 2 die accidently and 1 from unknown intent. o 50% Monroe County Adults With a Firearm in the Home 57% 44% 62% Total Male Female Under Years 60 & Older Income <$25K Income $25K Plus Of the 196 people who are shot but survive, 140 are from assault, 43 are shot accidently, 10 are suicide attempts, 2 are police interventions and 1 with an unknown intent. (Source: Brady Campaign to Prevent Gun Violence, There Are Too Many Victims of Gun Violence fact sheet, retrieved from: 51% 49% 44% 52% SOCIAL CONTEXT 89

92 Adult І MENTAL HEALTH AND SUICIDE Key Findings In 2015, 3% of Monroe County adults considered attempting suicide. 9% of adults had a period of two or more weeks when they felt so sad or hopeless nearly every day that they stopped doing usual activities. Adult Mental Health 3% of Monroe County adults considered attempting suicide in the past year. One percent (1%) of adults reported attempting suicide in the past year. In the past year, 9% of Monroe County adults had a period of two or more weeks when they felt so sad or hopeless nearly every day that they stopped doing usual activities, increasing to 12% of those ages Monroe County adults dealt with stress in the following ways: talk to someone they trust (52%), sleep (37%), eat more or less than normal (33%), exercise (31%), listen to music (31%), work on a hobby (26%), work (20%), take it out on others (13%), drink alcohol (11%), smoke tobacco (8%), meditate (6%), use prescription drugs (4%), use herbs or home remedies (3%), use illegal drugs (2%), gamble/lottery (2%), and other ways (14%). Adults would do the following if they knew someone who was suicidal: talk to them (69%), try to calm them down (53%), call a crisis line (47%), call (39%), take them to the emergency room (25%), call a friend (21%), and other (4%). Monroe County adults reported they or a family member were diagnosed with or treated for the following mental health issues: depression (43%), anxiety or emotional problems (34%), an anxiety disorder (33%), attention deficit disorder (ADD/ADHD) (31%), bipolar (24%), illicit drug abuse (12%), developmental disability (10%), post-traumatic stress disorder (PTSD) (8%), life-adjustment disorder (7%), a psychotic disorder (7%), and some other mental health disorder (8%). 36% indicated they or a family member had taken medication for one or more mental health issues. 30 Monroe County Number of Suicide Deaths, Total Deaths = 100 Number of Deaths (Source: MDCH, Vital Statistics) 90

93 The following graphs show the Monroe County suicide counts. The graphs show: In 2014, 64% of suicide deaths were males. In 2014, 81% of all Monroe County suicide deaths occurred to those ages years old. In 2014, there were 22 suicide deaths in Monroe County. Number of Cases Reported Number of Deaths Monroe County Suicide Number of Deaths by Gender Monroe Males (Source: MDCH, Vital Statistics) (Source: Monroe County Suicide Prevention Committee) 3 Monroe Females Monroe County Number of Suicide Deaths By Age Group 2014 Total Deaths = MENTAL HEALTH 91

94 The following graphs show the Michigan and Monroe County age-adjusted suicide mortality rates per 100,000 population. The graphs show: The Monroe County age-adjusted suicide mortality rate fluctuated from year to year, and was less than the Michigan rate from 2011 to The 2012 Monroe County age-adjusted suicide rate was higher than the state and national average. Monroe County and Michigan Age-Adjusted Suicide Mortality Rates Rate per 100,000 population Monroe Michigan Age-Adjusted Suicide Mortality Rates for Monroe County Residents, Michigan, and U.S. Rate per 100,000 population Monroe 2012 Michigan 2012 U.S (Source: MDCH, Vital Statistics, Statewide Fatal Injuries, updated , and CDC, Fast Stats, updated ) 92

95 Warning Signs for Suicide More than 90 percent of people who kill themselves are suffering from one or more psychiatric disorders, in particular: Major depression Bipolar depression Schizophrenia Drug abuse and dependence Alcohol abuse and dependence Post-Traumatic Stress Disorder (PTSD) Eating disorders Personality disorders The core symptoms of major depression are a down or depressed mood most of the day or a loss of interest or pleasure in activities that were previously enjoyed for at least two weeks, as well as: Changes in sleeping patterns Change in appetite or weight Intense anxiety, agitation, restlessness Fatigue or loss of energy Decreased concentration, indecisiveness, or poorer memory Feelings of hopelessness, worthlessness, self-reproach or excessive or inappropriate guilt Recurrent thoughts of suicide Prevention: Take it Seriously Fifty to 75% of all suicides give some warning of their intentions to a friend or family member. Recognize the Imminent Dangers: Threatening to hurt or kill oneself Talking or writing about death, dying, or suicide Looking for ways to kill oneself (weapons, pills, or other means) Has made plans or preparations for a potentially serious attempt (Source: American Foundation for Suicide Prevention, When You Fear Someone May Take Their Life, MENTAL HEALTH 93

96 Adult І ORAL HEALTH Key Findings The 2015, four-fifths (80%) of Monroe County adults had visited a dentist or dental clinic in the past year. The 2012 BRFSS reported that 67% of U.S. adults and 68% of Michigan adults had visited a dentist or dental clinic in the previous twelve months. More than three-quarters (79%) of Monroe County youth in grades 6-12 had visited the dentist for a check-up, exam, teeth cleaning, or other dental work in the past year. Access to Dental Care Monroe County Dental Care Resources 2013 General dentists- 48 Specialty Dentists- 7 Healthy Kids Dentists- 54 Number of dentists who treated Medicaid patients- 9 Medicaid Dental Coverage- Healthy Kids Dental Fee-for-Service, Adult (Source: Michigan Oral Health Coalition, 2013) In the past year, 80% of Monroe County adults had visited a dentist or dental clinic, decreasing to 68% of adults with annual household incomes less than $25,000. The 2012 BRFSS reported that 67% of U.S. adults and 68% of Michigan adults had visited a dentist or dental clinic in the previous twelve months. More than four-fifths (86%) of Monroe County adults with dental insurance have been to the dentist in the past year, compared to 65% of those without dental insurance. When asked the main reason for not visiting a dentist in the last year, 42% said cost, 18% said fear, apprehension, nervousness, pain, and dislike going, 15% had no oral health problems, 8% could not find a dentist who took Medicaid, 6% had not thought of it, 6% had other priorities, 4% said their dentist did not accept their medical coverage, 4% did not have/know a dentist, 3% could not find a dentist who treats special needs clients, 3% could not get to the office (no transportation), and 1% could not get in to the office/clinic. More than one-third (35%) of adults had one or more of their permanent teeth removed, increasing to 60% of those ages 60 and over. The 2012 BRFSS reported that 45% of U.S. adults and 43% of Michigan adults had one or more permanent teeth removed. The 2015 Health Assessment reports that 10% of Monroe County adults ages 60 and over had all of their permanent teeth removed. The 2012 BRFSS reported that 16% of U.S. adults and 13% of Michigan adults ages 65 and over had all of their permanent teeth removed. Monroe County youth last saw a dentist for a check-up, exam, teeth cleaning, or other dental work: less than a year ago (79%), 1 to 2 years ago (9%), More than 2 years ago (4%), never (1%), and do not know (7%). * 2012 BFRSS Data Adult Comparisons Adults who have visited the dentist in the past year Adults who have had one or more permanent teeth removed Monroe County 2015 Michigan 2013 U.S % 68%* 67%* 35% 45%* 43%* 94

97 The following graphs provide information about the frequency of Monroe County adult and youth dental visits. Examples of how to interpret the information on the first graph include: 80% of all Monroe County adults had been to the dentist in the past year, 92% of those under the age of 30, and 68% of those with incomes less than $25, % 80% 60% 40% 20% 0% 100% 80% 60% 40% 20% 0% 80% Monroe County Adults Visiting a Dentist in the Past Year 77% 82% 92% 77% Total Males Females Under Years 74% 68% 60 & Older Income <$25K Monroe County Youth Visiting a Dentist in the Past Year 79% 78% 78% 78% 80% 81% Income $25K Plus Total Males Females 13 or younger or older 76% ORAL HEALTH 95

98 Adult І PARENTING Key Findings The 2015 Health Assessment project identified that 78% of parents discussed bullying with their 6-to-17 year-old in the past year. More than four-fifths (83%) of parents indicated their child was physically active for at least 60 minutes 3 or more days per week. Parenting In the past 5 years, parents indicated their infant slept in the following places: crib/bassinette (with no bumper pads, blankets, and toys) (81%), pack n play (55%), in bed with them or another person (51%), car seat (42%), crib/bassinette (with bumper pads, blankets, and toys) (40%), swing (38%), couch or chair (21%), and the floor (6%). How to Talk to your Teen about Safe Sex Talk calmly and honestly about safe sex. Practice talking about safe sex with another adult before approaching your adolescent. Listen to your adolescent and answer his/her questions honestly. Topics that are appropriate for a safe sex discussion may include: STDs and prevention, peer pressure to have sex, birth control, different forms of sexuality, and date rape. (Source: American Academy of Pediatrics (AAP), Safer Sex Guidelines, adolescent/safesex.html) Parents reported their child experienced the following types of bullying in the past year: verbal (36%), indirect (14%), physical (11%), and cyber (4%). 86% of parents indicated their child was physically active for at least 60 minutes 3 or more days per week. 65% of children were physically active 5 or more days per week. 4% of children were not physically active, including 3% who were unable to be active. Parents discussed the following topics with their 6-to-17 year-old in the past year: Bullying (78%) Negative effects of marijuana and other drugs (38%) Screen-time (77%) Energy drinks (34%) Physical activity (65%) Violence (32%) Eating habits (61%) School/legal consequences of using tobacco/alcohol/other drugs (27%) Body image (50%) Abstinence/how to refuse sex (25%) Negative effects of tobacco (44%) Weight status (24%) Dating and relationships (43%) Birth control (23%) Negative effects of alcohol (43%) Condom use/safer sex/std prevention (22%) Social media issues (41%) Negative effects of misusing prescription medication (20%) Refusal skills/peer pressure (40%) o Anxiety/depression/suicide (20%) 96

99 Youth І WEIGHT STATUS Key Findings The 2015 Health Assessment identified that 17% of Monroe County youth were obese, according to Body Mass Index (BMI) by age. When asked how they would describe their weight, 30% of Monroe County youth reported that they were slightly or very overweight. 68% of youth were exercising for 60 minutes on 3 or more days per week. 89% of youth were involved in extracurricular activities. Youth Weight Status BMI for children is calculated differently from adults. The CDC uses BMI-for-age, which is gender and age specific as children s body fatness changes over the years as they grow. In children and teens, BMI is used to assess underweight, normal, overweight, and obese. In 2015, 17% of youth were classified as obese by Body Mass Index (BMI) calculations (2013 YRBS reported 13% for Michigan and 14% for the U.S.). 12% of youth were classified as overweight (2013 YRBS reported 16% for Michigan and 17% for the U.S.). 70% were normal weight, and 2% were underweight. 17% of Monroe County youth were classified as obese. 30% of youth described themselves as being either slightly or very overweight (2013 YRBS reported 29% for Michigan and 31% for the U.S.). Nearly half (46%) of all youth were trying to lose weight, increasing to 58% of Monroe County female youth (compared to 35% of males) (2013 YRBS reported 45% for Michigan and 48% for the U.S.). Monroe County youth reported doing the following to lose weight or keep from gaining weight in the past 30 days: o 50% of youth exercised. o 42% of youth drank more water. o 36% of youth ate more fruits and vegetables. o 29% of youth ate less food, fewer calories, or foods lower in fat. o 10% of youth skipped meals. o 3% reported going without eating for 24 hours or more (2013 YRBS reported 13% for Michigan and 13% for the U.S.). o 2% reported taking diet pills, powders, or liquids without a doctor s advice (2013 YRBS reported 6% for Michigan and 5% for the U.S.). o 2% vomited or took laxatives (2013 YRBS reported 5% for Michigan and 4% for the U.S.). o 2% reported smoking to lose weight. YOUTH WEIGHT Nutrition 11% of Monroe County youth ate 5 or more servings of fruits and vegetables per day. 81% ate 1 to 4 servings of fruits and vegetables per day. Monroe County youth consumed the following sources of calcium daily: milk (80%), other dairy products (57%), yogurt (36%), calcium-fortified juice (11%), other calcium sources (12%) and calcium supplements (5%). 97

100 32% of youth reported they drank energy drinks for the following reasons: to stay awake (58%), to get pumped up (26%), before games or practice (17%), to help them perform (9%), to mix with alcohol (9%), and some other reason (33%). 5% of youth reported they went to bed hungry because their family did not have enough money for food at least one night per week. <1% of youth went to bed hungry every night of the week. Physical Activity 68% of Monroe County youth participated in at least 60 minutes of physical activity on 3 or more days in the past week. 48% did so on 5 or more days in the past week (2013 YRBS reports 50% for Michigan and 47% for the U.S.), and 25% did so every day in the past week (2013 YRBS reports 27% for Michigan and the U.S.). 13% of youth did not participate in at least 60 minutes of physical activity on any day in the past week (2013 YRBS reports 15% for Michigan and the U.S.). The CDC recommends that children and adolescents participate in at least 60 minutes of physical activity per day. As part of their 60 minutes per day; aerobic activity, muscle strengthening, and bone strengthening are three distinct types of physical activity that children should engage in, appropriate to their age. Children should participate in each of these types of activities on at least three days per week. Monroe County youth spent an average of 3.3 hours on their cell phone, 1.6 hours watching TV, 1.2 hours on their computer/tablet and 1.0 hour playing video games on an average day of the week. Nearly one-quarter (23%) of youth spent 3 or more hours watching TV on an average day (2013 YRBS reported 27% for Michigan and 33% for the U.S.). 89% of youth participated in extracurricular activities. They participated in the following: sports or intramural programs (57%), exercising (outside of school) (47%), school club or social organization (32%), part-time job (25%), church or religious organization (20%), babysitting for other kids (19%), church youth group (19%), volunteering in the community (18%), caring for siblings after school (17%), caring for parents or grandparents (4%) or some other organized activity (Scouts, 4H, etc.) (12%). Monroe County 6 th -12 th Grade Youth did the following to lose weight in the past 30 days: Percent Exercised 50% Drank more water 42% Ate more fruits and vegetables 36% Ate less food, fewer calories, or foods lower in fat 29% Skipped meals 10% Went without eating for 24 hours 3% Took diet pills, powders, or liquids without a doctor s advice 2% Vomited or took laxatives 2% Smoked cigarettes 2% 98

101 The following graph shows the percentage of Monroe County youth who were classified as obese, overweight, normal weight, or underweight by Body Mass Index (BMI). Examples of how to interpret the information in the first graph include: 70% of all Monroe County youth were classified as normal weight, 17% were obese, 12% were overweight, and 2% were underweight for their age and gender. 100% 80% 60% 40% 20% 0% Monroe County Youth BMI Classifications 2% 1% 2% 4% < 1% 3% 70% 12% 17% 21% 69% 71% 9% 16% 8% 11% 7% 15% 10% 18% 21% Total Male Female 13 or younger 14 to & Older 81% Obese Overweight Normal Weight Underweight Physical Activity Facts 67% 66% Regular physical activity in childhood and adolescence improves strength and endurance, helps build healthy bones and muscles, helps control weight, reduces anxiety and stress, increases self-esteem, and may improve blood pressure and cholesterol levels. The U.S. Department of Health and Human Services recommends that young people ages 6 17 years participate in at least 60 minutes of physical activity daily. The percentage of high school students who attended physical education classes daily decreased from 42% in 1991 to 25% in 1995 and remained stable at that level until 2011 (31%). Regular physical activity: Helps build and maintain healthy bones and muscles. Helps reduce the risk of developing obesity and chronic diseases, such as diabetes, cardiovascular disease, and colon cancer. Reduces feelings of depression and anxiety and promotes psychological wellbeing. May help improve students academic performance, including academic achievement and academic behavior. (Sources: CDC, Adolescent and School Health, Updated: 2/19/2013, from: YOUTH WEIGHT 99

102 Youth Comparisons Monroe County 2015 (6 th -12 th ) Monroe County 2015 (9 th -12 th ) Michigan 2013 (9 th -12 th ) U.S (9 th -12 th ) Obese 17% 19% 13% 14% Overweight 12% 13% 16% 17% Described themselves as slightly or very overweight 30% 30% 29% 31% Trying to lose weight 46% 46% 45% 48% Went without eating for 24 hours or more 3% 4% 13% 13% Took diet pills, powders, or liquids without a doctor s advice 2% 3% 6% 5% Vomited or took laxatives 2% 2% 5% 4% Physically active at least 60 minutes per day on every day in past week 25% 27% 27% 27% Physically active at least 60 minutes per day on 5 or more days in past week 48% 50% 50% 47% Did not participate in at least 60 minutes of physical activity on any day in past 13% 14% 15% 15% week Watched TV 3 or more hours per day 22% 23% 27% 33% 100

103 Youth І TOBACCO USE Key Findings The 2015 Health Assessment identified that 7% of Monroe County youth in grades 6-12 were smokers, increasing to 17% of those ages 17 and older. Of those 6th -12th grade youth who currently smoked, 68% had tried to quit. Youth Tobacco Use Behaviors The 2015 health assessment indicated that 24% of Monroe County youth had tried cigarette smoking (2013 YRBS reported 36% for Michigan and 41% for the U.S.). 4% of those who had smoked a whole cigarette did so at 10 years old or younger, and another 25% had done so by 12 years old. The average age of onset for smoking was 13.6 years old. 5% of all Monroe County youth had smoked a whole cigarette for the first time before the age of 13 (2013 YRBS reported 8% for Michigan and 9% for the U.S.). In 2015, 7% of Monroe County youth were current smokers, having smoked at some time in the past 30 days (2013 YRBS reported 12% for Michigan and 16% for the U.S). 16% of current smokers smoked cigarettes daily. 2% of all Monroe County youth smoked cigarettes on 20 or more days during the past month (2013 YRBS reported that 4% of youth in Michigan smoked cigarettes on 20 or more days during the past month and 6% for the U.S). In 2015, 7% of Monroe County youth were current smokers, having smoked at some time in the past 30 days. About three-fourths 71% of Monroe County youth identified as current smokers were also current drinkers, defined as having had a drink of alcohol in the past 30 days. 52% of youth smokers borrowed cigarettes from someone else, 45% indicated they bought cigarettes from a store or gas station (2013 YRBS reported 18% for the U.S.), 32% gave someone else money to buy them cigarettes 29% took them from a family member, 29% said a person 18 years or older gave them the cigarettes, 3% took them from a store, and 6% got them some other way. No one reported getting them from the internet or a vending machine. Monroe County youth used the following forms of tobacco the most in the past year: e- cigarettes (17%), hookah (12%), cigarettes (12%), Black and Milds (7%), chewing tobacco or snuff (6%), swishers (5%), cigarillos (5%), cigars (4%), flavored cigarettes (4%), snus (2%), little cigars (1%), bidis (1%), and dissolvable tobacco products (<1%). About two-thirds (68%) of Monroe County 6th-12th grade youth smokers had ever tried to quit smoking in the past year (2013 YRBS reported 52% for Michigan and 48% for the U.S.). YOUTH TOBACCO Three-fifths (60%) of Monroe County youth were exposed to second hand smoke. Youth reported being exposed to second hand smoke in the following places; home (29%), another relative s home (27%), in the car (25%) at a friend s home (19%), fairgrounds (10%), and park/ball field (6%). 101

104 The following graph shows the percentage of Monroe County youth who smoke cigarettes. Examples of how to interpret the information include: 7% of all Monroe County youth were current smokers, 8% of males smoked, and 6% of females were current smokers. 30% Monroe County Youth Who Are Current Smokers 20% 17% 10% 7% 8% 6% 5% 2% 0% Total Male Female 12 to to & Older 17% of all Monroe County youth had vaped e-cigarettes in the past year. Behaviors of Monroe County Youth Current Smokers vs. Non-Current Smokers Youth Behaviors Current Smoker Non- Current Smoker Participated in extracurricular activities 87% 90% Have had sexual intercourse 82% 21% Exposed to second hand smoke 71% 59% Have had at least one drink of alcohol in the past 30 days 71% 17% Had used marijuana in the past 30 days 68% 8% Had 3 or more stressors 63% 49% Had been bullied in the past 12 months 50% 42% Misused prescription medications in the past 30 days 32% 4% Attempted suicide in the past 12 months 20% 5% Current smokers are those youth surveyed who have self-reported smoking at any time during the past 30 days. 102

105 Youth Comparisons Monroe County 2015 (6 th -12 th ) Monroe County 2015 (9 th 12 th ) Michigan 2013 (9 th 12 th ) U.S (9 th 12 th ) Ever tried cigarettes 24% 31% 36% 41% Current smokers 7% 9% 12% 16% Tried to quit smoking (of smokers) 68% 54% 52% 48% Smoked cigarettes on 20 or more days during the past month (of all youth) Smoked a whole cigarette for the first time before the age of 13 (of all youth) 2% 2% 4% 6% 5% 5% 8% 9% Electronic Cigarettes and Teenagers in the U.S. The percentage of U.S. middle and high school students who tried electronic cigarettes more than doubled from 2011 to E-cigarettes look like regular cigarettes, but they are operated by battery. An atomizer heats a solution of liquid, flavorings, and nicotine that creates a mist that is inhaled. The percentage of high school students who had ever used e-cigarettes rose from 4.7% in 2011 to 10% in In the same time period, high school students using e- cigarettes within the past 30 days rose from 1.5% to 2.8%. The percentage of middle school students who had ever used e-cigarettes also doubled from 1.4% to 2.7%. Altogether, as of 2012 more than 1.78 million middle and high school students in the US had tried e-cigarettes. 76% of current young e-cigarette users also smoked regular cigarettes. Some experts fear that e-cigarettes may encourage children to try regular cigarettes. Nicotine is a highly addictive drug. Many teens that start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine and conventional cigarettes." (Source: CDC, Press Release, September 5, 2013, & ACS, Electronic Cigarette Use Doubles Among Teenagers, September 9, 2013, YOUTH TOBACCO 103

106 Youth І ALCOHOL CONSUMPTION Key Findings In 2015, the Health Assessment results indicated that 48% of Monroe County youth in grades 6-12 had drank at least one drink of alcohol in their life, increasing to 68% of youth seventeen and older. 27% of those 6th-12th graders who drank, took their first drink at 12 years or younger. 21% of all Monroe County 6th-12th grade youth and 41% of those over the age of 17 had at least one drink in the past 30 days. Half (50%) of the 6th-12th grade youth who reported drinking in the past 30 days had at least one episode of binge drinking.10% of all youth drivers had driven a car in the past month after they had been drinking alcohol. Youth Alcohol Consumption In 2015, the Health Assessment results indicated that nearly half (48%) of all Monroe County youth (ages 12 to 18) had at least one drink of alcohol in their life, increasing to 68% of those ages 17 and older (2013 YRBS reports 60% for Michigan and 66% for the U.S.). 21% of youth had at least one drink in the past 30 days, increasing to 41% of those ages 17 and older (2013 YRBS reports 28% for Michigan and 35% for the U.S.). Of those who drank, 50% had five or more alcoholic drinks on an occasion in the last month and would be considered binge drinkers by definition, increasing to 60% of those ages 17 and older. Based on all youth surveyed, 11% were defined as binge drinkers, increasing to 25% of those ages 17 and older (2013 YRBS reports 17% for Michigan and 21% for the U.S.). Over one-quarter (27%) of Monroe County youth who reported drinking at some time in their life had their first drink at 12 years old or younger; 32% took their first drink between the ages of 13 and 14, and 42% started drinking between the ages of 15 and 18. The average age of onset was 13.5 years old. Of all Monroe County youth, 12% had drunk alcohol for the first time before the age of 13 (2013 YRBS reports 14% of Michigan youth drank alcohol for the first time before the age of 13 and 19% for the U.S.). Monroe County youth drinkers reported they got their alcohol from the following: someone gave it to them (33%)(2013 YRBS reports 33% for Michigan and 42% for the U.S.), an older friend or sibling bought it (24%), someone older bought it (21%), gave someone else money to buy it (13%), a parent gave it to them (12%), a friend s parent gave it to them (5%), bought it in a liquor store/ convenience store/gas station (4%), took it from a store or family member (3%), bought it at a restaurant/bar/club (3%), bought it with a fake ID (2%), bought it at a public event (1%), and got it some other way (25%). Monroe County youth drinkers reported usually drinking their alcohol in the past month at the following: at another person s home (70%), at their home (51%), at a restaurant, bar, or club (7%), at a public place such as a park, beach, or parking lot (5%), while riding in or driving a car or another vehicle (2%), at a public event such as a concert or sporting event (2%), and on school property (2%). During the past month, 19% of all Monroe County youth had ridden in a car driven by someone who had been drinking alcohol (2013 YRBS reports 20% for Michigan and 22% for the U.S.). 10% of youth drivers had driven a car in the past month after they had been drinking alcohol (2013 YRBS reports 6% for Michigan and 10% for the U.S.). 104

107 The following graphs show the percentage of Monroe County youth who have drank in their lifetime and those who are current drinkers. Examples of how to interpret the information include: 48% of all Monroe County youth have drank at some time in their life: 48% of males and 48% of females. 100% 80% 60% 40% 20% 60% 40% 20% 0% 0% Monroe County Youth Having At Least One Drink In Their Lifetime 48% 48% 48% 25% 50% 68% Total Male Female 12 to to & Older Based on all Monroe County youth surveyed, 11% were defined as binge drinkers. 21% Monroe County Youth Who Are Current Drinkers 24% 17% Total Male Female 12 to to & Older 3% 20% 41% YOUTH ALCOHOL 105

108 The following graph shows the percentage of Monroe County youth who were binge drinkers. Examples of how to interpret the information include: 50% of current drinkers binge drank in the past month, 59% of males, and 38% of females had binge drank. The table shows differences in specific risk behaviors between current drinkers and non-current drinkers. 100% Monroe County Youth Current Drinkers Who Binge Drank in Past Month* 80% 60% 50% 59% 50% 60% 40% 38% 39% 20% 0% Total Male Female 12 to to & Older *Based on all current drinkers. Binge drinking is defined as having five or more drinks on an occasion. 12% of Monroe County youth drinkers reported they got their alcohol from a parent giving it to them. Behaviors of Monroe County Youth Current Drinkers vs. Non-Current Drinkers Youth Behaviors Current Drinker Non- Current Drinker Participated in extracurricular activities 90% 90% Have had sexual intercourse 62% 16% Have been bullied in the past 12 months 55% 40% Have had 3 or more adverse childhood experiences 39% 19% Have used marijuana in the past 30 days 37% 6% Have smoked cigarettes in the past 30 days 24% 3% Misused prescription medications in the past 30 days 13% 4% Attempted suicide in the past 12 months 11% 4% Current drinkers are those youth surveyed who have self-reported drinking at any time during the past 30 days. Of all Monroe County youth, 12% had drunk alcohol for the first time before the age of

109 Youth Comparisons Monroe County 2015 (6 th -12 th ) Monroe County 2015 (9 th 12 th ) Michigan 2013 (9 th 12 th ) U.S (9 th 12 th ) Ever tried alcohol 48% 58% 60% 66% Current drinker 21% 28% 28% 35% Binge drinker (of all youth) 11% 14% 17% 21% Drank for the first time before age 13 (of all youth) 12% 12% 14% 19% Rode with someone who was drinking 19% 22% 20% 22% Drank and drove (of youth drivers) 10% 10% 6% 10% Obtained the alcohol they drank by someone giving it to them 33% 40% 33% 42% Teen Binge Drinking: All Too Common Risks Associated with Binging: It is estimated that alcohol consumption is responsible for about 80,000 deaths in the US each year. Binge drinking has also been associated with many health problems, including: Heart disease Stroke Cancer Liver disease Chemical dependency Pregnancy STDs Alcohol poisoning MRI scans of the brains of teens that drank heavily showed damaged nerve tissue compared to those who did not. Studies have shown that alcohol can cause long-term damage to the brain and impair memory, coordination and movement. (Source: Psychology Today, Teen Angst, Teen Binge Drinking: All Too Common, 1/26/2013, from: YOUTH ALCOHOL 107

110 Youth І DRUG USE Key Findings In 2015, 12% of Monroe County 6th-12th grade youth had used marijuana at least once in the past 30 days, increasing to 27% of those ages 17 and older. 6% of youth used medications that were not prescribed for them or took more than prescribed to get high at some time in their life. Youth Drug Use In 2015, 12% of all Monroe County youth had used marijuana at least once in the past 30 days, increasing to 27% of those over the age of 17. The 2013 YRBS found a prevalence of 18% for Michigan youth and a prevalence of 23% for U.S. youth who had used marijuana at least once in the past 30 days. During the past 12 months, 8% of all Monroe County youth reported that someone had offered, sold, or given them an illegal drug on school property, increasing to 11% of high school youth (2013 YRBS reports 24% for Michigan and 22% for the U.S.). Youth reported they had been pressured to engage in the following in the past year: drink alcohol (12%), use drugs (9%), smoke cigarettes (8%), participate in sexual intercourse (5%), and participate in other sexual activities (6%). Monroe County youth have tried the following in their life: o 4% used K2/spice o 4% of youth used inhalants, (2013 YRBS reports 7% for Michigan and 9% for the U.S.) o 2% misused cough syrup o 2% used cocaine, (2013 YRBS reports 4% for Michigan and 6% for U.S.) o 2% used steroids without a doctor s prescription, (2013 YRBS reports 3% for Michigan and U.S.) o 2% misused over-the-counter medications o 2% used ecstasy/mdma (2013 YRBS reports 7% for the U.S.) o 2% used liquid THC o 2% used posh/salvia/synthetic marijuana o 1% misused hand sanitizer o 1% used methamphetamines, (2013 YRBS reports 3% for Michigan and the U.S.) o 1% used heroin, (2013 YRBS reports 3% for Michigan 2% and for the U.S.) o 1% had been to a pharm party/used skittles o 1% used bath salts o 1% used Cloud 9 o 1% used GhB 6% of youth reported they used medications that were either not prescribed for them or took more than prescribed to feel good, high or more alert at some time in their life. Of those who misused medication, they reported using the following: Ritalin, Adderall, Concerta, or other ADHD medications (11%), Tranquilizers/sleeping pills, such as Valium or Xanax, barbiturates, Seconal, Ativan or Klonopins (10%), Vicodin (10%), Codeine, Demerol, Morphine, Percodan or Dilaudid (6%) steroids (4%), OxyContin (2%), and Suboxone or Methadone (1%). No one reported using Ultram. Youth who misused prescription medications got them in the following ways: a friend gave it to them (54%), a parent gave it to them (18%), they took it from a friend or family member (18%), bought it from a friend (11%), another family member gave it to them (7%), bought it from someone else (7%), and the internet (4%). 108

111 The following graphs are data from the 2015 Monroe County Health Assessment indicating youth lifetime drug use and marijuana use in the past 30 days. Examples of how to interpret the information include: 2% of youth have used cocaine at some point in their lives, and 4% of youth have used inhalants at some point in their life. 15% 10% 5% 0% 30% 25% 20% 15% 10% 5% 2% Monroe County Youth Lifetime Drug Use 2% 2% 2% 1% 1% 1% 2% 1% 1% 0% Cocaine Heroin Meth Steroids Inhalants Total Male Female 12% of Monroe County youth had used marijuana in the past month. 12% Monroe County Youth Marijuana Use in Past Month 11% 13% 4% 4% 9% 4% 3% 27% 5% YOUTH DRUG USE 0% Total Male Female 13 or younger 14 to or older 109

112 The following graph is data from the 2015 Monroe County Health Assessment indicating youth lifetime prescription medication abuse. Examples of how to interpret the information include: 6% of youth have misused medication at some point in their life. 25% Monroe County Youth Lifetime Prescription Medication Abuse 20% 15% 10% 5% 6% 5% 7% 2% 8% 8% 0% Total Male Female 13 or younger 14 to or older N/A - Not available Youth Comparisons Youth who used marijuana in the past month Monroe County 2015 (6 th -12 th ) Monroe County 2015 (9 th -12 th ) Michigan 2013 (9 th -12 th ) U.S (9 th -12 th ) 12% 16% 18% 23% Ever used methamphetamines 1% 1% 3% 3% Ever used cocaine 2% 3% 4% 6% Ever used heroin 1% 2% 3% 2% Ever used steroids 2% 3% 3% 3% Ever used inhalants 4% 4% 7% 9% Ever misused medications 6% 8% 16% 18% Ever used ecstasy/mdma 2% 2% N/A 7% Ever been offered, sold, or given an illegal drug by someone on school property in the past year 8% 11% 24% 22% Drug Facts: Drugged Driving Vehicle accidents are the leading cause of death among youth people aged 16 to 19. When teens relative lack of driving experience is combined with the use of marijuana or other substances that affect cognitive and motor abilities, the results can be tragic. According to the 2013 National Survey on Drug Use and Health (NSDUH), an estimated 9.9 million people aged 12 or older reported driving under the influence of illicit drugs during the year prior to being surveyed. After alcohol, THC (delta-9-tetrahydrocannabinol), the active ingredient in marijuana is the substance most commonly found in the blood of impaired drivers, fatally injured drivers, and motor vehicle crash victims. Studies in several localities have found that approximately 4 to 14 percent of drivers who sustained injury or died in traffic accidents tested positive for THC. (Source: National Institute on Drug Abuse, The Science of Drug Abuse & Addiction: Drug Facts: Drugged Driving, revised 12-14) 110

113 Youth І SEXUAL BEHAVIOR Key Findings In 2015, just over one-quarter (26%) of Monroe County youth have had sexual intercourse, increasing to 57% of those ages 17 and over. 30% of youth had participated in oral sex and 5% had participated in anal sex. 23% of youth participated in sexting. Of those who were sexually active, 58% had multiple sexual partners. Four Monroe County schools did not ask sexual behavior questions. Youth Sexual Behavior Four Monroe County schools did not ask sexual behavior questions. Just over one-quarter (26%) of Monroe County youth have had sexual intercourse, increasing to 57% of those ages 17 and over. The 2013 YRBS reports 38% for Michigan and 47% of U.S. youth have had sexual intercourse. 30% of youth had participated in oral sex, increasing to 60% of those ages 17 and over. 5% of youth had participated in anal sex, increasing to12% of those ages 17 and over. 23% of youth had participated in sexting, increasing to 38% of those ages 17 and over. 24% of youth had viewed pornography, increasing to 33% of males and 38% of those ages 17 and over. Of those youth who were sexually active in their lifetime, 42% had one sexual partner and 58% had multiple partners. 29% of all Monroe County sexually active youth had 4 or more partners (2013 YRBS reports 28% for Michigan). 8% of all Monroe County youth had 4 or more sexual partners (2013 YRBS reports 8% for Michigan and 15% for the U.S.). Of those youth who were sexually active, 14% had done so by the age of 13. Another 48% had done so by 15 years of age. The average age of onset was 15.2 years old. Of all youth, 3% were sexually active before the age of 13 (2013 YRBS reports 3% for Michigan and 6% for the U.S). 57% of youth who were sexually active used condoms to prevent pregnancy, 35% used birth control pills, 7% used the withdrawal method, 5% used a shot, patch or birth control ring, 2% used an IUD and 5% used some other method. 5% reported they were gay or lesbian. However, 11% were engaging in intercourse without a reliable method of protection and 9% reported they were unsure. 37% of Monroe County youth, who had participated in any sexual activity, always used protection when engaging in oral, anal, or sexual intercourse. Of those Monroe County youth that reported not always using protection when engaging in oral, anal, or sexual intercourse, they gave the following reasons: did not want to use protection (23%), did not have protection available to them (22%), their partner did not want to use protection (19%), and it did not occur to them (16%). Monroe County youth had experienced the following: had sex in exchange for something of value such as food, drugs, shelter or money (2%), been pregnant (2%), wanted to get pregnant (1%), had a child (1%), had been treated for an STD (1%), had a miscarriage (<1%), and got someone pregnant (<1%). No one reported trying to get pregnant or having an abortion. SEXUAL BEHAVIOR 111

114 The following graphs show the percentage of Monroe County youth who participated in sexual intercourse and oral sex. Examples of how to interpret the information include: 26% of all Monroe County youth had sexual intercourse, 20% of males, and 32% of females had sex. 75% Monroe County Youth Who Had Sexual Intercourse 57% 50% 25% 26% 20% 32% 15% 0% Total Male Female 13 or Younger 14 to & Older 1% 11% of Monroe County youth who were sexually active were not using a reliable method of protection to prevent pregnancy. 75% Monroe County Youth Who Participated in Oral Sex 60% 50% 25% 30% 26% 33% 21% 1% 0% Total Male Female 13 or Younger 14 to & Older 112

115 The following graphs show the percentage of Monroe County youth who participated in anal sex and sexting. Examples of how to interpret the information include: 5% of all Monroe County youth participated in anal sex, 4% of males, and 6% of females. 50% 25% 0% 75% 50% 25% 0% Monroe County Youth Who Participated in Anal Sex 12% 5% 4% 6% 3% 0% Total Male Female 13 or Younger 14 to & Older Monroe County Youth Who Participated in Sexting 38% 23% 26% 21% 23% 3% Total Male Female 13 or Younger 14 to & Older SEXUAL BEHAVIOR 113