Southeastern Health Equity Report Card: Focusing on Factors Related to Health Care Access, Healthy Food Access, and Cultural Competency
Southeastern Health Equity Council
Acknowledgements We would like to thank the following for their efforts in the research and development of this Southeastern Health Equity Report Card.
Southeastern Health Equity Council Members: Alabama Bettina Byrd-Giles, MA, BA John Hankins, RN, EdD, MBA Keecha Harris, DrPH, RD Jeongah Kim, PhD Tonya Perry, PhD, MSW
Florida Alma Dixon, EdD, MSN Elizabeth C. Lense, DDS Carl Patten, JD, MPH Colleen Reinert, MPH Fern Webb, PhD
Georgia Levather Johnson, JD, RN, BSN Arnulfo A. Muralles, MS, MPH Romero M. Stokes, MPA Alfred Yin
Kentucky C. Anneta Arno, PhD, MPH Delquan Dorsey Korana Durham, MPH, BA Sheila Pressley, DrPH Susan Zepeda, PhD
Mississippi Mina Li, MD, PhD, CSM Mary Mixon, MSN Joanie Perkins, PhD, MSW Evelyn Walker, MD, MPH John Whitfield, JD, ThD
North Carolina G. Rumay Alexander Ronny A. Bell, PhD Sylvia Flack, RN, EdD, MSN, BSN Gladys Lundy, MA Meka Sales, MS, CHES
South Carolina Saundra Glover, PhD, MBA Marcy L. Hayden Brenda Hughes, MPH Denethia B. Sellers, PhD, MSW Sabra Slaughter, PhD
Tennessee Renee S. Frazier, MHSA, FACHE Cherry Houston, PhD, MPH RN Pamela Hull, PhD Tionna Jenkins, PhD, MPH Kenneth Robinson, MD, MDiv
Amirah Abdullah, MSPH SHEC Intern Gabriela Alcalde, DrPH, MPH SHEC Expert Stakeholder Foundation for a Healthy Kentucky Mississippi Rural Health Association SHEC Fiscal Sponsor Visit our Website at http://region4.npa-rhec.org/ Copyright ©2014 by Southeastern Health Equity Council All rights Reserved
1
Table of Contents Executive Summary ............................................................................................4 Introduction & Grading System ...........................................................................8 Demographic Distribution ...................................................................................9 Socioeconomic Status ....................................................................................... 10 POVERTY............................................................................................................. 10 EDUCATION ......................................................................................................... 11 EMPLOYMENT ...................................................................................................... 12 Cultural Competency In Health Care ................................................................. 13 FOREIGN BORN POPULATION ................................................................................... 13 ENGLISH AS A SECOND LANGUAGE POPULATION ......................................................... 14 STATE ACTION ON CULTURAL AND LINGUISTIC COMPETENCY EDUCATION ....................... 15 PHYSICAL ACTIVITY .............................................................................................. 17 FOOD INSECURITY ................................................................................................ 18 FOOD DESERTS .................................................................................................... 19 STATES WITH STATE-LEVEL FOOD POLICY COUNCILS ................................................. 20 NUMBER OF LOCAL-LEVEL FOOD POLICY COUNCILS IN EACH STATE.............................. 21 Health Care Access ............................................................................................ 22 HEALTH INSURANCE .............................................................................................. 22 STATES DECISIONS ON EXPANDING MEDICAID ........................................................... 23 USAGE OF FEDERAL OR STATE HEALTH INSURANCE EXCHANGES .................................. 24 Selected Health Outcomes ................................................................................ 25 LIFE EXPECTANCY ................................................................................................ 25 OBESITY AMONG CHILDREN .................................................................................... 26 OBESITY AMONG ADULTS ....................................................................................... 27 DIABETES............................................................................................................ 28 CARDIOVASCULAR DISEASE MORTALITY ................................................................... 29 Implications For Practice .................................................................................. 30 HEALTH CARE ACCESS .......................................................................................... 30 FOOD ACCESS ...................................................................................................... 30 CULTURAL COMPETENCY ........................................................................................ 30 DATA COLLECTION AND REPORTING ........................................................................ 31 CONCLUSION ........................................................................................................ 31
2
3
Executive Summary What is the Southeastern Health Equity Council? The Southeastern Health Equity Council (SHEC) is one of ten regional health equity councils in the U.S. formed in 2011 to implement the National Partnership for Action to End Health Disparities (NPA). The vision of the SHEC is a region free of disparities in health and health care, where all people attain the highest level of health. The mission of the SHEC is to coordinate efforts in the Southeastern region to achieve health equity through policy changes, effective programs, and greater awareness. A non-federal body, the SHEC’s membership draws from academia, health care, government, non-profit organizations, and the private sector. Its membership includes 40 individuals with content expertise in medicine, nutrition, nursing, public health, social work, business, and law. The SHEC represents the interests of residents of Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee. The SHEC strives to advocate for institutional- and state-level policy changes that can reduce health disparities. In particular, the SHEC focuses on three targeted areas of activity: 1) Health Care Access, 2) Healthy Food Access, and 3) Cultural Competence.
What is the Southeastern Health Equity Report Card? The Southeastern region experiences higher rates of illness and death from many diseases compared to the rest of the country, with certain groups of people impacted more than others. This situation diminishes the region’s potential for economic and societal advancement. The SHEC embraces a data-informed approach to change the social determinants that reinforce health disparities. The purpose of this report card is to identify where health disparities exist for key indicators related to health care access, healthy food access, and cultural competency. The report card draws on several publicly available sources of tabulated data that are, at minimum, broken down by state; we also include subgroup-level data, when available. To better understand the landscape in the Southeast, the SHEC used grades to illustrate disparities within and across the states. The SHEC defined a grading system that compares each data point to one of several possible benchmarks (see the “Grading System” section, for more details). The report card highlights key areas of consideration for policy efforts related to these three target areas, and it establishes a benchmark against which to compare progress in the future. In addition, the report card calls attention to gaps in data collection and public reporting.
4
Key Findings Health Care Access
The Southeastern region illustrated that roughly 74% of its population, aged 18-64, has health insurance, which is lower than the national average (79%). In addition, only 68% of Blacks/African Americans and 54% of Hispanics and Latinos have health insurance, compared to 78% of Whites.
Kentucky is the only state in the Southeast that has opted to expand its Medicaid program with funding from the Affordable Care Act (ACA) to provide more lowincome individuals access to health care services. Kentucky is also the only state in the Southeast to create a state-run health insurance exchange under the ACA.
Food Access
All of the Southeastern states scored an “F” in food insecurity. Most scored poorly on the percentage of the population living in food deserts (where no full-service grocery store exists in the vicinity), and almost all states scored a “C” in employment.
All of the Southeastern states scored poorly on the consumption of fruits and vegetables, physical activity, obesity rates, and diabetes rates, with clear disparities for these health indicators.
All Southeastern states have convened local- or state-level food policy councils to address issues of food access through collective, multisectoral efforts.
Cultural Competency
This region is home to the largest Black/African American population in the country. More than 13 million Blacks/African Americans live in the Southeast and contribute substantially to the minority population, which in total, makes up 37% of the population. In addition, the Southeastern region is home to a growing American Indian, Appalachian, and impoverished population.
The foreign-born population and the population speaking English as a second language have increased substantially in the Southeast over recent decades. Florida, Georgia, and North Carolina have the largest foreign-born populations in this region, but states such as Alabama, Kentucky, Mississippi, and Tennessee have seen an increase greater than 50% since 2006. South Carolina ranks #1 in the Country for growth of the Hispanic population.
Cultural competency education helps health care providers be responsive to diverse cultural beliefs and practices, preferred languages, literacy and health literacy levels, and other patient needs. Although a law requiring cultural competency education in health care professional training programs has been proposed in many of the Southeastern states, no state has passed such legislation to date.
Data Collection and Reporting Data were missing in tables for one of three reasons:
For some indicators, the sample size for a subcategory was so small as to preclude an estimate. This was often the case for Pacific Islanders, American Indians and Alaskan Natives, and sometimes Asians. 5
For many indicators, the source agency collects the information for the subcategories we sought to include, but the data are not publicly reported in a form that is broken down by the same subcategories. This was most often applied to urban/rural classification and sometimes to disability status, although for some indicators (e.g., English as a second language, food deserts, and food insecurity) none of the subcategories were reported by the source.
In other cases, data on some of the subcategories are not collected by the original data source. For example, none of the data sources collected information about sexual orientation. In addition, disability status is not collected on death certificates for mortality data.
Implications for Practice Health Care Access
In the 7 Southeastern states that have opted not to expand Medicaid as of January 2014, over 2.5 million adults who are currently uninsured would have been eligible for coverage under Medicaid expansion.1
Outreach efforts should be enhanced to inform people of their new healthcare coverage choices, possible subsidies for insurance premiums, and how to enroll.
Expanding Medicaid and coverage through affordable private health insurance plans in Southeastern states would contribute to lower mortality rates due to lifethreatening conditions, and lower overall healthcare costs through prevention and proper management of chronic conditions.
Food Access
A food-financing program at the state or regional level could increase access to fullservice grocery stores in areas designated as food deserts.
Such programs would yield immediate economic benefits by creating jobs, as well as long-term benefits of slowing down the obesity epidemic by increasing access to affordable, healthier foods.
Cultural Competency
To increase the competency of the health care workforce, state-level laws and/or licensure and certification policies should be enacted requiring that cultural competency education be provided to new and existing health care professionals.
Indicators measuring the delivery of cultural competent services need to be collected by healthcare facilities and reported to the public in order to assess their impact on health outcomes.
Data Collection and Reporting
In state and national surveys, missing data due to small sample size can be remedied by oversampling racial and ethnic groups with small population sizes.
The data that are currently being collected on the subcategories included here should be tabulated and made available to the general public in a format that does not require users to download and analyze large datasets on their own.
1
According to Urban Institute Health Policy Center
6
Agencies should consider the feasibility of including sexual orientation in future data collection and reporting, as well as merging death certificate data with disability data to report mortality rates by disability status.
Conclusion The SHEC will use the Southeastern Health Equity Report Card to inform a range of decision makers in the public and private sectors. This report card frames the rationale to engage policy makers in a conversation to leverage upstream approaches, which impact many of the negative indicators noted in this document.
7
Introduction & Grading System The purpose of this report card is to identify where health disparities exist for key indicators related to health care access, healthy food access, and cultural competency. The report card draws on several publicly available sources of tabulated data that are, at minimum, broken down by state; we also include subgroup level data when available. To better understand the landscape in the Southeast, the SHEC used the grades to illustrate disparities within and across the states. The SHEC defined a grading system that compares each data point to one of several possible benchmarks. Most grades were assigned based on comparison to the national Healthy People 2020 goals.2 Healthy People 2020 are used as a benchmark since it provides science-based national objectives every 10 years to assess health improvements for all Americans.3 For indicators that do not have a Healthy People 2020 goal or for indicators that did not illustrate an appropriate benchmark for the purposes of this report card, grades were assigned based on the change from 2009 to 2012 (or other years, where noted, if data not available for 2009)* For indicators that did not have data from a previous year for comparison, grades were determined based on the national average. The following guidelines will be used to assign grades: A = Equal or better than HP 2020 goal or >25% improved from 2009 to 2012 or >25% improved from national average B = 1-30% worse than HP 2020 goal or > 10 – 25% improved from 2009 to 2012 or >10 – 25% improved from national average C = > 30 – 60% worse than HP 2020 goal or between 10% improved and 10 % worse from 2009 to 2012 or between 10% improved and 10% worse from national average D = > 60 – 90% worse than HP 2020 goal or > 10 -25% worse from 2009 to 2012 or >10 – 25% worse from national average F = > 90% worse than HP 2020 goal or > 25% worse from 2009 to 2012 or >25% worse from national average Each grade is indicated in the tables using the color scheme below: A
B
C
D
F
Note: Due to changes in data collection from the Centers for Disease Control and Prevention (CDC), results from the 2011 Behavioral Risk Factor Surveillance System (BRFSS) are not comparable to results from earlier years. When comparison years are used to determine the grade using BRFSS data, 2010 data are used. Where national averages are used for comparison, grades will not be available in the national average column. *Other years include 2003, 2006, and 2011 Source: U.S. Census Bureau. 2011 American Community Survey 2
3
For more information on Healthy People 2020, click here.
8
Demographic Distribution
Tennessee
South Carolina
Mississippi
9.7
4.7
6.4
87.8 8.0
59.4 37.4
70.1 21.7
67.0 27.9
77.9 16.7
0.3 3.3 0.1
0.2 1.2 0.0
0.4 0.9 0.0
1.2 2.2 0.0
0.3 1.4 0.0
0.3 1.4 0.0
22.9
9.0
3.0
2.7
8.6
5.2
4.6
48.4 51.6
48.9 51.1
49.0 51.0
49.1 50.9
48.6 51.4
48.5 51.5
48.6 51.4
48.7 51.3
15.9 84.1
12.7 87.3
11.8 88.2
16.5 83.5
15.8 84.2
13.0 87.0
13.5 86.5
15.0 85.0
48.7 41.0
87.4 8.8
65.4 24.9
41.0 41.6
27.6 50.7
54.9 33.9
55.8 33.7
54.4 33.6
Georgia
3.0
Florida
North Carolina
Total Population (millions) Race (%) White African American American Indian/ Alaska Native Asian Pacific Islander Ethnicity (%) Hispanic Gender (%) Male Female Disabled (%) Disabled Non-Disabled Urban/Rural Status (%) Urban Rural
Kentucky
Alabama
Southeast Demographic Distribution
4.8
19.1
9.8
4.4
69.1 26.7
76.3 16.0
60.7 30.8
0.5 1.1 0.0
0.3 2.4 0.1
3.9
Source: U.S. Census Bureau, 2011 American Community Survey
9
Socioeconomic Status Poverty
Poverty continues to increase in the Southeast region. In 2009, the U.S. Census reported that 17% of individuals were living below the poverty line. In 2011, this proportion increased to 19%. Poverty status is determined by family size and annual income. For example, a four-person family is poor if their annual income is below $22,350.
African Americans, American Indian/Alaska Native, Hispanics, and the Disabled population are more likely to be impoverished than any other group.
Poverty has been associated with poor health, high unemployment rates, the lack of access to health care services, and the lack of access to healthy food choices.
Regional
Alabama
Florida
Georgia
Kentucky
Mississippi
North Carolina
South Carolina
Tennessee
Percent of population living in poverty (2011) Race White African American American Indian/ Alaska Native Asian Pacific Islander Ethnicity Hispanic Gender Male Female Disability Status Disabled Non-Disabled Urban/Rural Status Urban Rural Sexual Orientation Heterosexual Homosexual Bisexual
National
Socioeconomic Status: Poverty
B 15.9
B 19.0
B 19.0
B 17.0
B 19.1
B 19.1
C 22.6
B 17.9
B 18.9
B 18.3
13.0 28.1 29.5
14.3 31.2 26.6
13.5 32.4 20.5
14.0 29.6 25.6
14.0 27.9 27.7
17.5 32.7 27.1
13.6 36.5 23.1
13.6 28.0 27.0
13.4 31.1 38.3
15.1 31.1 23.6
12.8 ϕ
13.0 9.9*
12.4 ϕ
12.6 9.9
12.7 ϕ
13.2 ϕ
14.7 ϕ
14.0 ϕ
11.7 ϕ
12.9 ϕ
25.8
32.1
32.8
22.7
33.6
33.1
34.3
34.9
31.9
33.5
14.7 17.2
17.4 20.5
17.2 20.8
16.0 17.9
17.8 20.4
17.5 20.7
20.3 24.6
16.4 19.2
17.2 20.4
16.8 19.7
28.6 13.7
30.1 15.3
29.5 15.8
28.2 15.1
29.7 16.2
32.4 14.9
30.5 15.0
28.9 15.2
30.0 15.8
31.5 14.6
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
Source: U.S. Census Bureau, 2011 American Community Survey. Grading is based on comparison to the National Healthy People 2020 goal for poverty (15.1%). Note: Poverty status was determined for all people except for institutionalized people, military members, college dormitories, and individuals under 15 years of age. If a family’s total income is less than the average expected income, they live in poverty. The average expected income is based on family size and annual earnings. *The estimate is statistically unstable. ϕ Sample size too small to report Δ Data may not be publicly reported by source δ Data not collected by source
10
Education
Since 2009, the U.S. and most of the Southeast states have experienced less than a 10% reduction in the number of individuals with less than a high school graduate education.
The disabled population has experienced an increase in the number of adults with less than a high school graduate education. Policies/programs should be developed to improve education attainment among this population.
Low education attainment is a risk factor for many health outcomes. High education attainment results in an increase in life expectancy and greater employment opportunities.
Regional
Alabama
Florida
Georgia
Kentucky
Mississippi
North Carolina
South Carolina
Tennessee
Percent of people 25 years and older who have less than a high school graduate education (2012) Race White African American American Indian/ Alaska Native Asian Pacific Islander Ethnicity Hispanic Gender Male Female Disability Status** Disabled Non-Disabled Urban/Rural Status Urban Rural Sexual Orientation Heterosexual Homosexual Bisexual
National
Socioeconomic Status: Education
C 13.6
C 15.4
C 16.0
C 13.5
C 15.0
B 16.2
C 17.7
C 14.8
C 15.1
B 14.9
11.6 16.8 21.2
13.6 19.1 28.6*
14.3 20.1 ϕ
11.9 19.7 ϕ
13.5 16.3 ϕ
16.0 16.0 ϕ
14.0 24.3 ϕ
12.8 17.5 28.6
12.3 21.1 ϕ
14.0 17.5 ϕ
14.3 14.6
14.4* ϕ
ϕ ϕ
14.5 ϕ
12.5 ϕ
ϕ ϕ
ϕ ϕ
16.5 ϕ
ϕ ϕ
14.1 ϕ
36.0
36.3
39.6
23.6
41.4
32.9
31.8
46.6
35.6
38.8
14.3 13.0
16.8 14.2
17.3 14.9
14.3 12.6
16.1 14.0
17.8 15.0
19.6 16.0
16.8 13.2
16.4 14.0
15.7 14.1
18.1 13.9
23.9 14.7
27.1 15.1
17.7 12.9
21.1 15.5
25.0 14.7
26.9 17.6
22.5 14.3
22.9 14.7
27.8 12.6
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
Source: U.S. Census Bureau, 2012 American Community Survey. Grading is based on year comparison (2009). Note: 2009 data used to compare are as follows: AL (17.9), FL (14.7), GA (16.1), KY (18.3), MS (19.6), NC (15.7), SC (16.4), TN (16.9), Regional (17.0), and National (14.7). Each subgroup is compared to the 2009 value. Note: Percentage represents the population over 25 who have less than a high school education and includes those who entered high school but did not complete/graduate from high school or receive its equivalent (GED). *The estimate is statistically unstable. **Source: National Center on Birth Defects and Developmental Disabilities (2011). Grading is based on year comparison (2009). Percentage represents the population over 18 who are disabled and have less than a high school education and includes those who entered high school but did not complete/graduate from high school or receive its equivalent (GED). ϕ Sample size too small to report Δ Data may not be publicly reported by source δ Data not collected by source
11
Employment
The unemployment rate for the Southeast is currently above the national average at 10.6%. Since 2009 the rates have remained steady, with all groups seeing little to no improvement.
High rates of unemployment, on a state or local level, have been linked to poor health, obesity, inactive lifestyles, poverty, high crime rates, and lack of access to health care insurance and services.
Regional
Alabama
Florida
Georgia
Kentucky
Mississippi
North Carolina
South Carolina
Tennessee
Unemployment Rate (2012) Race White African American American Indian/ Alaska Native Asian Pacific Islander Ethnicity Hispanic Gender Male Female Disability Status Disabled Non-Disabled Urban/Rural Status Urban Rural Sexual Orientation Heterosexual Homosexual Bisexual
National
Socioeconomic Status: Employment
C 9.4
C 10.6
C 10.0
C 11.5
C 11.0
C 9.3
C 11.3
C 10.8
C 11.2
B 9.5
8.0 16.8 15.9
8.6 16.6 14.9
7.8 15.7 20.2
10.1 18.9 18.3
8.6 16.5 18.5
8.9 14.0 Φ
7.5 18.1 18.4
8.9 17.3 12.7
8.9 17.1 12.7
8.3 15.5 18.1
7.1 13.8
5.9 Φ
4.9 Φ
6.9 Φ
6.8 Φ
3.4 Φ
6.6 Φ
6.6 Φ
6.7 Φ
5.6 Φ
11.4
9.4
9.2
11.2
10.5
10.1
6.3
11.2
10.1
6.8
8.9 8.5
9.7 9.9
8.6 9.9
11.0 10.6
10.1 10.4
8.9 8.1
9.7 11.0
10.1 10.0
10.3 10.4
8.7 9.1
18.0 6.3
19.8 6.8
17.6 6.2
23.0 7.7
20.1 7.3
17.7 5.7
19.3 7.1
21.6 7.1
21.5 7.2
17.3 6.1
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
Source: U.S. Census Bureau, 2012 American Community Survey. Grading is based on year comparison (2009). Note: 2009 data used to compare are as follows: AL (11.1), FL (12.1), GA (11.2), KY (10.1), MS (10.7), NC (11.0), SC (11.7), TN (11.1), Regional (11.1), and National (9.9). Each subgroup is compared to the 2009 value. Note: The unemployment rates represent individuals who have been unemployed for more than 15 weeks. ϕ Sample size too small to report Δ Data may not be publicly reported by source δ Data not collected by source
12
Cultural Competency in Health Care Foreign Born Population
The foreign-born population has been gradually increasing in the Southeast. Although Florida, Georgia, and North Carolina have the largest foreign-born populations, states such as Alabama, Kentucky, Mississippi, and Tennessee have seen an increase of greater than 50% since 2006.
As the population continues to diversify, it is important to provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultures.
Grading is not applicable since it is difficult to determine what signifies an improvement to a state’s foreign-born population.
Regional
Alabama
Florida
Georgia
Kentucky
Mississippi
North Carolina
South Carolina
Tennessee
Percent of population that is foreign born (2011) Race White African American American Indian/ Alaska Native Asian Pacific Islander Ethnicity Hispanic Gender Male Female Disability Status Disabled Non-Disabled Urban/Rural Status Urban Rural Sexual Orientation Heterosexual Homosexual Bisexual
National
Cultural Competency in Health Care: Foreign Born Population
13.1
8.0
3.4
19.6
9.2
3.2
2.2
7.4
4.8
4.8
3.9 8.6 5.1
2.0 4.6 14.1*
0.8 0.9 ϕ
5.9 20.0 17.9
2.4 5.5 16.9
0.9 4.2 ϕ
0.7 0.2 ϕ
2.0 2.4 2.5
1.9 0.7 ϕ
1.4 2.6 19.2
66.6 22.1
70.9 24.1*
72.4 ϕ
71.2 24.1
70.3 ϕ
75.1 ϕ
64.4 ϕ
66.8 ϕ
73.1 ϕ
73.5 ϕ
36.2
44.9
45.8
48.4
47.0
39.7
40.8
47.0
44.1
46.1
6.4 6.7
3.5 3.4
1.8 1.2
9.2 10.4
5.0 4.7
1.7 1.6
1.2 0.9
3.9 3.6
2.5 2.3
2.5 2.4
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
Source: U.S. Census Bureau, 2011 American Community Survey. Grading is not applicable since it is difficult to determine what signifies an improvement to a state’s foreign-born population. Use national data as a referent point. Note: Individuals are considered foreign-born if they have indicated that they were either a U.S. citizen by naturalization or they were not a citizen of the United States. Individuals born in Puerto Rico or other U.S. Island areas are not considered foreign-born. *The estimate is statistically unstable ϕ Sample size too small to report Δ Data may not be publicly reported by source δ Data not collected by source
13
English as a Second Language Population The English as a 2nd language population is continuing to increase in the
Southeast, with Florida, Georgia, and North Carolina having the largest population growth, in this category, since 2006. It is important that the health care and public health community offer language
assistance to individuals who have limited English proficiency to facilitate safe timely and quality access to all health care services. Efforts should be taken to assure that all staff, providers, and others who work closely with our growing diverse population, are competent to provide culturally and linguistically appropriate services. Subgroup level data is not publicly available for this indicator, emphasizing a disparity in data reporting. In addition, Grading is not applicable since it is difficult to determine what signifies an improvement to a state’s English as a 2nd language population.
Regional
Alabama
Florida
Georgia
Kentucky
Mississippi
North Carolina
South Carolina
Tennessee
Percent of population that list English as their 2nd language (2011) Race White African American American Indian/ Alaska Native Asian Pacific Islander Ethnicity Hispanic Gender Male Female Disability Status Disabled Non-Disabled Urban/Rural Status Urban Rural Sexual Orientation Heterosexual Homosexual Bisexual
National
Cultural Competency in Health Care: English as a Second Language Population
20.8
9.9
5.2
27.6
13.3
4.8
2.2
10.7
6.6
6.9
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ
Δ
Δ
Δ
Δ
Δ
Δ
Δ
Δ
Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
Δ Δ Δ
Source: U.S. Census Bureau, 2011 American Community Survey. Use national data as a referent point. Note: Individuals who spoke a language other than English at home were classified as the population with English as a 2nd language. Tabulations of language spoken at home includes individuals 5 years old and over. Δ Data may not be publicly reported by source δ Data not collected by source
14
State Action on Cultural and Linguistic Competency Education
None of the Southeastern states have passed legislation regarding cultural competency education.
It is important to educate and train health organization’s governance, leadership, and workforce in culturally and linguistically appropriate policies and practices.
Through implementation of cultural competency education, providers are able to be responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.
Region IV: State Action on Cultural and Linguistic Competency Education/Training among Health Care Professionals4
Kentucky
Tennessee
North Carolina
South Carolina Mississippi
Alabama
Georgia
Florida
Map prepared by the Southeastern Health Equity Council on November 14, 2013. Note: States have denied, proposed, and/or passed legislation regarding cultural competency education. Data reflects the most recent information available. Source: U.S. Department of Health and Human Services, Office of Minority Health, CLAS Legislation Map. 4
15
Healthy Eating, Physical Activity, and Food Access Food Consumption
States in the Southeast are gradually increasing their intake of 5 or more fruits or vegetables per day. However, North Carolina and South Carolina have decreased since 2003.
Fruit and vegetable consumption may reduce the risk of chronic disease, cancer, and support weight management.
To increase fruit and vegetable consumption, access to quality and affordable fruits and vegetables is essential.
Regional
Alabama
Florida
Georgia
Kentucky
Mississippi
North Carolina
South Carolina
Tennessee
Percent of adults who consume 5 or more fruits or vegetables per day (2009) Race White African American American Indian/ Alaska Native Asian Pacific Islander Ethnicity Hispanic Gender Male Female Disability Status Disabled Non-Disabled Urban/Rural Status Urban Rural Sexual Orientation Heterosexual Homosexual Bisexual
National
Healthy Eating, Physical Activity and Food Access: Food Consumption
C 23.4
C 21.1
C 20.3
B 24.4
B 24.5
B 21.1
C 16.8
D 20.6
D 17.4
C 23.3
24.1 21.3 ϕ
21.5 19.6 ϕ
20.5 19.5 ϕ
25.4 24.5 ϕ
24.1 25.6 ϕ
20.7 21.9 ϕ
17.2 15.8 ϕ
21.1 18.3 ϕ
18.0 14.3 ϕ
24.7 17.1 Φ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
Φ Φ
21.5
19.9*
ϕ
21.4
22.6
ϕ
ϕ
15.7
ϕ
Φ
19.2 27.7
17.9 23.9
18.2 22.3
20.2 28.3
21.0 27.7
17.7 24.1
14.8 18.7
17.4 23.7
13.9 20.6
20.3 26.1
22.7 24.0
19.0 21.7
16.7 21.5
23.5 24.6
25.0 24.5
19.1 21.8
14.2 17.8
17.8 21.4
16.0 17.8
19.9 24.2
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
Δ Δ Δ
Source: Centers for Disease Control and Prevention, 2009 Behavioral Risk Factor Surveillance System. Grading based on year comparison (2003). 2011 data are not comparable. Note: 2003 data used to compare are as follows: AL (22.6), FL (23.6), GA (23.0), KY (18.2), MS (17.9), NC (23.1), SC (22.3), TN (22.2), Regional (21.6), and National (22.6). Each subgroup is compared to the 2003 value. Note: Fruit & vegetable consumption is determined for individuals who consume 5 fruits or vegetables per day *The estimate is statistically unstable. ϕ Sample size too small to report Δ Data may not be publicly reported by source δ Data not collected by source
16
Physical Activity
Individuals living in the Southeastern region are less likely to engage in physical activity when compared to the National average.
Obesity in adults continues to increase, indicating a need to get more of this population physically active. The risk of adverse health outcomes increase as obesity rises. Program implementation is pertinent among this population, particularly among the African American and disabled populations.
A physically active lifestyle can reduce the risk of chronic disease, improve a person’s mental health, and increase life expectancy.
Regional
Alabama
Florida
Georgia
Kentucky
Mississippi
North Carolina
South Carolina
Tennessee
Percent of adults who do not engage in physical activity (2011) Race White African American American Indian/ Alaska Native Asian Pacific Islander Ethnicity Hispanic Gender Male Female Disability Status Disabled Non-Disabled Urban/Rural Status Urban Rural Sexual Orientation Heterosexual Homosexual Bisexual
National
Healthy Eating, Physical Activity and Food Access: Physical Activity
49.0
D 57.0
D 58.9
C 53.8
D 54.3
D 54.3
F 62.5
C 53.6
D 54.6
F 64.0
48.2 57.0 ϕ
55.2 63.6 ϕ
57.8 65.3 ϕ
49.7 64.6 ϕ
51.1 61.0 ϕ
54.3 ϕ ϕ
59.9 68.1 ϕ
51.5 62.8 ϕ
53.7 55.7 ϕ
63.5 67.7 ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
53.5
55.0*
ϕ
59.2
ϕ
ϕ
ϕ
50.7
ϕ
ϕ
46.6 51.4
53.3 60.5
52.2 65.0
51.5 55.9
52.8 55.7
51.8 56.6
57.9 66.7
48.9 58.1
49.9 59.0
61.1 66.7
63.4 47.9
70.0 53.4
71.0 55.2
62.7 51.4
67.1 51.9
69.9 49.3
76.3 58.0
67.5 49.9
66.9 51.1
78.4 60.1
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
Source: Centers for Disease Control and Prevention, 2011 Behavioral Risk Factor Surveillance System. Grading based on comparison to the 2011 National average (49.0%). Note: Adults who do not engage in physical activity was determined if individuals do not participate in 30+ minutes of moderate physical activity five or more days per week, or vigorous physical activity for 20+ minutes three or more days per week. The data indicates the proportion of individuals who are not receiving the recommended amount of exercise per week. *Data not reliable ϕ Sample size too small to report Δ Data may not be publicly reported by source δ Data not collected by source
17
Food Insecurity
The Southeast rates for food insecurity are more than 100% higher than the Healthy People 2020 goal of 6%.
Food insecure households are less likely to consume foods that are beneficial to health and longevity, and they are less likely to engage in physical activity.
Food insecurity has been associated with malnutrition, digestive diseases, and short life expectancies.
Subgroup level data is not publicly available for this indicator, emphasizing a disparity in data reporting.
Regional
Alabama
Florida
Georgia
Kentucky
Mississippi
North Carolina
South Carolina
Tennessee
Percent of households with food insecurity (2009-2011) Race White African American American Indian/ Alaska Native Asian Pacific Islander Ethnicity Hispanic Gender Male Female Disability Status Disabled Non-Disabled Urban/Rural Status Urban Rural Sexual Orientation Heterosexual Homosexual Bisexual
National
Healthy Eating, Physical Activity and Food Access: Food Insecurity
F 14.7
F 16.1
F 18.2
F 15.4
F 17.4
F 16.4
F 14.2
F 17.1
F 14.8
F 15.2
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ
Δ
Δ
Δ
Δ
Δ
Δ
Δ
Δ
Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
Source: USDA, Economic Research Service using Current Population Survey Food Security Supplement data. Grading is based on comparison to the National Healthy People 2020 goal for food insecurity (6.0%). Note: Food insecurity exists if individuals report reduced quality, variety, or desirability of diet and have little to no indication of food intake. It also exists if individuals report multiple indications of disrupted eating patterns and reduced food intake. Δ Data may not be publicly reported by source δ Data not collected by source
18
Food Deserts
Compared to the national average (23.6%), many of the Southeast states have more than 24% of the population living in areas that do not have access to fresh, healthy, and affordable foods. Kentucky is the only state that had a lower average than the U.S., at 17.5%.
Food desert areas are more likely to have fast food restaurants as the primary source of nutrition, which increases the population’s risk for obesity and cardiovascular diseases.
Subgroup level data is not publicly available for this indicator, emphasizing a disparity in data reporting.
Regional
Alabama
Florida
Georgia
Kentucky
Mississippi
North Carolina
South Carolina
Tennessee
Percent of population living in census tracts designated as food deserts (2010) Race White African American American Indian/ Alaska Native Asian Pacific Islander Ethnicity Hispanic Gender Male Female Disability Status Disabled Non-Disabled Urban/Rural Status Urban Rural Sexual Orientation Heterosexual Homosexual Bisexual
National
Healthy Eating, Physical Activity and Food Access: Food Deserts
23.6
D 26.1
C 25.8
D 26.9
F 31.5
A 17.5
D 26.0
C 24.8
D 28.6
D 27.4
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ
Δ
Δ
Δ
Δ
Δ
Δ
Δ
Δ
Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
Source: USDA, 2010 Food Access Atlas. Grading is based on comparison to the 2010 National Average (23.6%) Note: Food deserts are defined as urban neighborhoods and rural towns without access to fresh, healthy, and affordable foods. A community is considered a food deserts if individuals living in urban areas are more than a mile away or if individuals living in rural areas are more than 10 miles away from fresh fruits and vegetables. Δ Data may not be publicly reported by source δ Data not collected by source
19
States with State-Level Food Policy Councils
The Southeast states do not currently have a Healthier Food Retail policy implemented at the state level. However, some of the states have created councils to influence state food policy.
Every state in the Southeast, except Kentucky, has a state-level food policy council in place to work towards assuring that the population has access to affordable and healthy food selections.
This policy works to support building and renovation of new food retail stores and to increase access to healthy fruits and vegetables.
Region IV: States with State-Level Food Policy Councils5
Kentucky
Tennessee
North Carolina
South Carolina Mississippi
Alabama
Georgia
Florida
Prepared by the Southeastern Health Equity Council on July 31, 2013. Note: State-level food policy councils exist to influence local, county, or regional food policy and to coordinate the work of the area food system stakeholders. This map includes councils of various types at different stages of development. Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity, and Obesity. 2013 State Indicator Report on Fruits and Vegetables. 5
20
Number of Local-Level Food Policy Councils in Each State
Every state in the Southeast, except Mississippi, has food policy councils on a local level.
Local-level food policy councils work to influence policy in communities that have an increase in food insecurity and food deserts.
These councils support improved food environments for healthy eating and fruits and vegetable access by encouraging the development of retail stores. These councils also support farm institutions, and promote healthy food practices in schools, work sites, and community organizations.
Region IV: Number of Local-Level Food Policy Councils In Each State6
Kentucky
Tennessee
North Carolina
South Carolina Mississippi
Alabama
Georgia
Florida
Prepared by the Southeastern Health Equity Council on July 31, 2013. Note: Local food policy councils exist to influence local, county, or regional food policy and to coordinate the work of the area food system stakeholders. This map includes councils of various types at different stages of development. Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity, and Obesity, 2013 State Indicator Report on Fruits & Vegetables. 6
21
Health Care Access Health Insurance
African Americans and Hispanics are less likely to have health insurance compared to other racial/ethnic groups in the Southeast and the U.S.
Health insurance provides access to clinical care, including preventive services. Those who do not have health insurance are more likely to have poor health conditions and high medical costs.
Regional
Alabama
Florida
Georgia
Kentucky
Mississippi
North Carolina
South Carolina
Tennessee
Percent of adults (1864) with health insurance (2011) Race White African American American Indian/ Alaska Native Asian Pacific Islander Ethnicity Hispanic Gender Male Female Disability Status Disabled Non-Disabled Urban/Rural Status Urban Rural Sexual Orientation Heterosexual Homosexual Bisexual
National
Health Care Access: Health Insurance
B 78.7
B 74.2
B 77.8
B 70.0
B 71.0
B 77.7
C 69.3
B 75.1
B 74.6
B 78.3
84.0 73.3 ϕ
78.8 68.4 ϕ
80.8 71.6 ϕ
77.8 64.6 ϕ
78.0 65.1 ϕ
78.8 70.7 ϕ
74.6 61.8 ϕ
81.3 70.2 ϕ
79.3 67.7 ϕ
79.6 75.6 ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
62.9
54.6
70.7
54.2
40.0
65.3
65.8
36.8
55.1
48.8
76.7 81.2
71.8 76.6
76.7 78.9
66.7 73.2
68.7 73.4
75.4 80.1
66.3 72.1
73.1 77.2
72.2 76.9
75.6 80.9
85.1 80.9
82.6 79.4
82.7 81.8
81.3 74.7
80.0 73.5
84.9 80.9
86.7 84.1
82.1 78.7
82.7 78.3
80.5 82.8
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
Source: Centers for Disease Control and Prevention, 2011 Behavioral Risk Factor Surveillance System. Grading is based on the National Healthy People 2020 goal for health insurance (100%). Note: This indicator represents the population who has any type of health insurance. ϕ Sample size too small to report Δ Data may not be publicly reported by source δ Data not collected by source
22
States Decisions on Expanding Medicaid
The Affordable Care Act (ACA) is expected to increase the number of people insured in the U.S. States have the ability, through the ACA, to expand Medicaid coverage to increase health care access to low income individuals.
Kentucky is currently the only state in the Southeast that has decided to expand their Medicaid program to cover individuals up to 138% of the Federal Poverty Level.
Medicaid expansion has the potential to save state government money while extending health care coverage to low-income Americans.
Region IV: States Decisions on Expanding Medicaid7
Kentucky
Tennessee
North Carolina
South Carolina Mississippi
Alabama
Georgia
Florida
Prepared by the Southeastern Health Equity Council on November 14, 2013. Note: Data reflects the most recent information available. Last updated on October 22, 2013 by the Kaiser Family Foundation. Source: Kaiser Family Foundation, 2013 KCMU Analysis. 7
23
Usage of Federal or State Health Insurance Exchanges
In the Southeast, Kentucky is currently the only state that has established a state-based exchange. The other states have indicated that they will default to a federally facilitated exchange.
In the U.S., 27 states have defaulted to a federal exchange, 17 declared a statebased exchange, and 7 have declared a partnership with the federal government to operate an exchange.
Health insurance exchanges create the opportunity for states to improve health outcomes and reduce health disparities by making insurance more affordable, ensuring a basic level of coverage and increasing access to health care services.
States who default to a federal-based exchange, forfeit some level of state control, limiting states’ ability to determine the needs of its population.
Region IV: Decision for Usage of Federal or State Health Insurance Exchanges8
Kentucky
Tennessee
North Carolina
South Carolina Mississippi
Alabama
Georgia
Florida
Prepared by the Southeastern Health Equity Council on July 31, 2013. Note: Data reflects the most recent information available. Last updated on June 20, 2013 by the Kaiser Family Foundation. Source: Kaiser Family Foundation 8
24
Selected Health Outcomes Life Expectancy
African Americans and men living in the Southeast have shorter life expectancies than their counterparts.
Disparities in life expectancies are highly due to deaths from cancer, diabetes, and cardiovascular diseases.
High infant mortality rates, poverty, unemployment, and the lack of access to health care services play a key role in an individuals’ expected lifespan.
Regional
Alabama
Florida
Georgia
Kentucky
Mississippi
North Carolina
South Carolina
Tennessee
Life Expectancy at Birth (in Years) (2010) Race White African American American Indian/ Alaska Native Asian Pacific Islander Ethnicity Hispanic Gender Male Female Disability Status Disabled Non-Disabled Urban/Rural Status Urban Rural Sexual Orientation Heterosexual Homosexual Bisexual
National
Selected Health Outcomes: Life Expectancy
78.9
C 76.8
C 75.4
C 79.4
C 77.2
C 76.0
C 75.0
C 77.8
C 77.0
C 76.3
78.9 74.6 ϕ
77.2 73.9 ϕ
76.0 72.9 ϕ
79.1 75.8 ϕ
77.6 74.7 ϕ
76.0 73.5 ϕ
76.1 72.4 ϕ
78.3 74.7 76.6
77.8 74.0 ϕ
76.7 72.9 ϕ
86.5 ϕ
87.1* ϕ
85.3 ϕ
88.9 ϕ
88.0 ϕ
ϕ ϕ
ϕ ϕ
88.9 ϕ
ϕ ϕ
84.2 ϕ
82.8
83.2*
ϕ
83.1
ϕ
ϕ
ϕ
ϕ
83.2
ϕ
76.3 81.3
74.0 79.5
72.6 78.2
76.6 82.3
74.6 79.7
73.4 78.5
71.9 78.0
75.1 80.4
74.0 79.8
73.5 79.0
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
Source: Centers for Disease Control and Prevention, 2010 National Center for Health Statistics. Grading is based on comparison to the 2010 National average (78.9 years). Note: Life expectancy is defined as the average number of years infants would live if they experienced the age-specific death rates present during the year they were born. *The estimate is statistically unstable. ϕ Sample size too small to report Δ Data may not be publicly reported by source δ Data not collected by source
25
Obesity Among Children
Obesity rates continue to increase, affecting all children regardless of race, ethnicity, or gender.
Children who are obese are at an increased risk of developing chronic diseases in their adult life compared to those who are not obese.
Physical activity and healthy food choices reduce the risk of obesity in children. Schools play a critical role in supporting healthy eating and physical activity.
Regional
Alabama
Florida
Georgia
Kentucky
Mississippi
North Carolina
South Carolina
Tennessee
Percent of children (10-17) who are obese (BMI above 95th percentile) (2011) Race White African American American Indian/ Alaska Native Asian Pacific Islander Ethnicity Hispanic Gender Male Female Disability Status Disabled Non-Disabled Urban/Rural Status Urban Rural Sexual Orientation Heterosexual Homosexual Bisexual
National
Selected Health Outcomes: Obesity Among Children
D 13.0
C 14.7
D 17.0
D 11.5
D 15.0
B 16.5
B 15.8
C 12.9
B 13.3
C 15.2
11.5 18.2 17.5
12.5 17.9 ϕ
15.1 19.6 ϕ
9.6 15.7 ϕ
12.8 17.6 ϕ
16.1 19.5 ϕ
13.1 18.2 ϕ
9.7 17.1 ϕ
9.9 17.6 ϕ
13.9 18.0 ϕ
9.8 21.4
10.4* ϕ
ϕ ϕ
10.4 ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
14.1
17.0*
ϕ
11.4
16.5
ϕ
ϕ
16.5
ϕ
23.4
16.1 9.8
17.8 11.4
19.7 14.3
15.2 7.7
18.2 11.7
20.6 12.1
18.2 13.5
14.8 10.9
18.1 8.4
17.9 12.4
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
Source: Centers for Disease Control and Prevention, 2011 Youth Risk Behavior Surveillance System. Grading is based on year comparison (2009). Note: 2009 data used to compare for the state overall are as follows: AL (13.3), FL (10.2), GA (12.3), KY (17.3), MS (18.1), NC (13.2), SC (16.5), TN (15.7), Regional (14.6), and National (11.8). Each subgroup is compared to the 2009 value. Note: Obesity among children is defined as a BMI at or above the 95 th percentile for children of the same age and sex. *The estimate is statistically unstable. ϕ Sample size too small to report Δ Data may not be publicly reported by source δ Data not collected by source
26
Obesity Among Adults
Obesity continues to increase in the Southeast, with African Americans having a higher risk, compared to Whites. The disabled population is also at an increased risk compared to the non-disabled.
Obesity continues to increase, indicating a need to engage the entire population in physical activity to reduce obesity rates and prevent the onset of new cases.
Obesity places individuals at an increased risk for cancer, chronic diseases, and osteoporosis.
Alabama
Florida
Georgia
Kentucky
Mississippi
North Carolina
South Carolina
Tennessee
Gender Male Female Disability Status Disabled Non-Disabled Urban/Rural Status Urban Rural Sexual Orientation Heterosexual Homosexual Bisexual
Regional
Percent of adults (1864) who are obese (BMI≥30.0) (2011) Race White African American American Indian/ Alaska Native Asian Pacific Islander Ethnicity Hispanic
National
Selected Health Outcomes: Obesity Among Adults
27.8
C 30.1
D 32.0
C 26.6
C 28.0
C 30.4
F 34.9
C 29.1
D 30.8
C 29.2
26.5 36.7 ϕ
27.6 40.2 ϕ
29.8 40.1 ϕ
24.9 35.7 ϕ
25.0 36.8 ϕ
29.5 43.2 ϕ
30.7 42.9 ϕ
26.2 40.7 ϕ
27.0 42.3 ϕ
27.9 40.2 ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
28.9
26.6
28.6
27.8
26.4
22.3
26.8
29.0
25.0
ϕ
28.3 27.4
29.2 31.1
32.3 31.8
27.7 25.6
26.7 29.3
29.6 31.1
32.4 37.3
28.3 30.0
28.6 33.0
28.0 30.4
38.1 23.9
40.4 25.3
41.3 27.7
35.5 23.1
39.4 24.3
41.9 24.9
42.0 27.2
40.9 25.3
42.1 26.9
39.8 23.1
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
Source: Centers for Disease Control and Prevention, 2011 Behavioral Risk Factor Surveillance System. Grading based on comparison to the 2011 National Average (27.8%). Note: Obesity among adults is defined as a BMI of 30 or higher. ϕ Sample size too small to report Δ Data may not be publicly reported by source δ Data not collected by source
27
Diabetes
In 2011, the Southeast region was #1, compared to other regions, for diagnosed cases of diabetes and hypertension, which places individuals at an increased risk for heart disease, blindness, and kidney failure.
The disabled population is at an increased risk for diabetes. Programs should be implemented to improve mobility and initiate healthy lifestyle changes.
Access to healthy food choices and the promotion of physical activity may reduce the risk of diabetes diagnosis.
Alabama
Florida
Georgia
Kentucky
Mississippi
North Carolina
South Carolina
Tennessee
American Indian/ Alaska Native Asian Pacific Islander Ethnicity Hispanic Gender Male Female Disability Status Disabled Non-Disabled Urban/Rural Status Urban Rural Sexual Orientation Heterosexual Homosexual Bisexual
Regional
Percent of adults diagnosed with diabetes (2010) Race White African American
National
Selected Health Outcomes: Diabetes
D 8.7
D 10.9
F 13.2
D 10.4
C 9.7
C 10.0
D 12.4
C 9.8
D 10.7
C 11.3
8.0 13.5
10.1 14.2
11.8 16.5
10.1 13.1
9.1 12.4
9.9 13.1
11.0 14.9
9.1 14.6
8.9 14.1
10.6 14.7
ϕ
ϕ
ϕ
ϕ
ϕ
ϕ
ϕ
ϕ
ϕ
Φ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
ϕ ϕ
Φ Φ
7.9
9.4
8.1
9.6
8.2
9.1
14.7
5.3
ϕ
10.9
9.0 8.4
10.9 11.0
12.5 13.9
11.7 9.2
9.3 10.1
10.2 9.8
12.0 12.6
9.5 10.0
10.8 10.6
11.0 11.6
17.8 7.0
20.4 8.0
21.4 10.2
17.9 8.0
19.5 7.3
19.4 6.9
23.5 8.6
19.3 7.2
19.8 7.8
22.3 7.8
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
Δ Δ Δ
Source: Centers for Disease Control and Prevention, 2010 Behavioral Risk Factor Surveillance System. Grading based on year comparison (2006). Note: 2006 data used to compare are as follows: AL (10.0), FL (8.5), GA (9.1), KY (9.9), MS (10.9), NC (9.1), SC (9.6), TN (10.7), Regional (9.7), and National (7.5). Each subgroup is compared to the 2006 value. Note: Diabetes is defined as a disease that is caused by an increase in blood glucose levels. Data above are representing the population that was told by a physician they have diabetes. ϕ Sample size too small to report Δ Data may not be publicly reported by source δ Data not collected by source
28
Cardiovascular Disease Mortality
Compared to 2006 rates, cardiovascular disease diagnosis has decreased substantially in the Southeast. Although rates are decreasing, they remain higher than the national average.
In 2010, the Southeast accounted for 21% of heart disease mortality in the U.S. This may be due to factors such as obesity, diabetes, and hypertension affecting this population at a substantially higher rate than other states in the U.S.
Limited access to healthy food choices can lead to poor diets and higher levels of cardiovascular disease.
Tennessee
C 221.4
C 286.3
C C C C 329.9 242.4 267.5 298.3
271.8 220.8 84.5
303.4 238.0 88.2*
350.6 293.2 75.1
318.0 183.9 62.4
243.6 198.5 ϕ
296.2 226.0 ϕ
366.0 258.9 277.2 316.8 282.2 220.2 258.7 241.5 127.1 ϕ ϕ Φ
ϕ ϕ
63.6 ϕ
61.8 ϕ
76.6 ϕ
57.6 ϕ
50.5 ϕ
76.5 ϕ
37.8 ϕ
79.5 ϕ
68.5 Φ
79.5
38.8
25.9*
142.7
23.4
26.3
27.0
16.0
28.9
20.3
252.7 252.7
289.8 276.1
330.5 328.1
305.4 269.5
225.6 217.4
292.2 280.6
δ δ
δ δ
δ δ
δ δ
δ δ
δ δ
δ δ
δ δ
δ δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
Δ Δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
δ δ δ
South Carolina
Georgia
C 287.1
North Carolina
Florida
Mississippi
Alabama C 329.3
C 252.7
Regional C 282.8
National Cardiovascular Disease Death Rate Per 100,000 Population (2010) Race White African American American Indian/ Alaska Native Asian Pacific Islander Ethnicity Hispanic Gender Male Female Disability Status Disabled Non-Disabled Urban/Rural Status Urban Rural Sexual Orientation Heterosexual Homosexual Bisexual
Kentucky
Selected Health Outcomes: Cardiovascular Disease Mortality
330.5 246.3 285.0 302.7 329.4 238.7 251.0 294.2
Source: Centers for Disease Control and Prevention, 2010 WONDER. Grading based on year comparison (2006). Note: 2006 data used to compare are as follows: AL (353.2), FL (315.3), GA (240.8), KY (317.0), MS (354.5), NC (263.7), SC (277.7), TN (316.4), Regional (304.8), and National (276.1). Each subgroup is compared to the 2006 value. Note: Cardiovascular disease is defined as any disease that affects your cardiac function. Data above includes diseases of the heart, hypertension, renal disease, cerebrovascular diseases, and disorders of the circulatory system, influenza/pneumonia, and lower respiratory infections. *The estimate is statistically unstable. ϕ Sample size too small to report Δ Data may not be publicly reported by source δ Data not collected by source
29
Implications for Practice Health Care Access
In Kentucky, over 185,000 adults who were previously uninsured will now qualify for Medicaid under the Medicaid expansion. In the 7 Southeastern states that have opted not to expand Medicaid as of January 2014, over 2.5 million adults who are currently uninsured would have been eligible for coverage under Medicaid expansion.9
Enrolling previously uninsured individuals in new health insurance plans available through health insurance exchanges will provide more individuals with the opportunity to receive quality health care. Outreach efforts should be enhanced to inform people of their new healthcare coverage choices, possible subsidies for insurance premiums, and how to enroll.
Expanding Medicaid and coverage through affordable private health insurance plans in Southeastern states would contribute to lower mortality rates due to lifethreatening conditions and lower overall healthcare costs through prevention and proper management of chronic conditions. In addition, coverage expansion would place Southeastern states closer to meeting the national “Healthy People 2020” objective of achieving 100% of the population covered by health insurance by the year 2020.
Food Access
A well-defined food-financing program at the state or regional level may increase access to full-service grocery stores in areas designated as food deserts.
Such programs would yield immediate economic benefits by creating jobs, as well as long-term benefits of slowing down the obesity epidemic by increasing access to affordable, healthier foods.
Research by the Tennessee Grocery Task Force indicates that the creation of 10-15 full service grocery stores in defined food deserts will create 1,500 new jobs, provide a new tax base, create $9 million in new payroll dollars, and generate $91 million in retail sales to support the investment of $30-40 million.10
Cultural Competency
Cultural competency in health care – specifically, a working system that provides culturally and linguistically appropriate services (CLAS) – has the potential to reduce health disparities and improve health outcomes in the Southeast.
To meet the needs of the increasingly diverse population in the Southeast, it is important to prepare a competent workforce that focuses on providing quality health care services to all people.
To increase the competency of the health care workforce, state-level laws and/or licensure and certification policies should be enacted requiring that cultural competency education be provided to new and existing health care professionals.
9
According to Urban Institute Health Policy Center For more information on the research conducted by the TN Grocery Task Force, please visit Policy Link website.
10
30
Data Collection and Reporting
These lapses in data collection and reporting limit the ability to identify disparities and track changes over time in health outcomes and factors that impact health for diverse subgroups of the U.S. population. Lack of available data can also impact decisions for funding public programs and other programs affecting those most in need, thereby potentially exacerbating health disparities.
In state and national surveys, missing data due to small sample size can be remedied by oversampling racial and ethnic groups with small population sizes.
The data that are currently being collected on the subcategories included here should be tabulated and made available to the general public in a format that does not require users to download and analyze large datasets on their own.
Agencies should consider the feasibility of including sexual orientation in future data collection and reporting, as well as merging death certificate data with disability data to report mortality rates by disability status.
Conclusion The SHEC will use the Southeastern Health Equity Report Card to inform a range of decision makers in the public and private sectors through electronic distribution, webinars, and targeted dissemination. This report card frames the rationale to engage policy makers in a conversation to leverage upstream approaches, which impact many of the negative indicators noted in this document. The Report Card is positioned to complement current reports on health equity, to inspire the production of additional reports, and to highlight the need for data collection and sampling issues among some of the most underserved populations.
31
