Healthy Montgomery Community Health Improvement Process Quantitative Needs Assessment: HEALTH SECTION

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1 Introduction In order to effectively evaluate and identify priority areas within our community, we need to understand the status of the health and well being of our residents including health related and well being related risk behaviors, health status, access to health care, and health outcomes (including illness and death). To provide a broad overview of health and well being in Montgomery County the beginning of this section provides an overview of life expectancy and leading causes of death among our residents. The specific health and well being topics covered in this section are aggregated in to the following topic areas: Access to Health Services Immunizations and Infectious Diseases Cancer Chronic Diseases including Diabetes, Heart Disease and Stroke, and Respiratory Diseases Healthy Living and Disease Prevention including Wellness and Lifestyle; Exercise, Nutrition and Weight; and Prevention and Safety Maternal, Infant and Child Health including Maternal, Fetal and Infant Health and Family Planning Behavioral Health including Mental Health and Mental Disorders and Substance Abuse Assessment of specific health and well being topics Each topic area has the following sections to provide a comprehensive assessment of the most currently available quantitative findings as well as community perspectives captured during the Healthy Montgomery Community Conversations series. Generally, the analyses are organized by the health topic areas used by the Healthy Montgomery Web site and include additional information where available to further describe the topic area being assessed. Each health topic includes: An introductory paragraph that provides the overall context of the topic area. Summary of Key Data Findings presents the Healthy Montgomery indicators results, including subpopulation indicator findings, when available. The text in bold is the wording of the Healthy Montgomery indicator. Graphic highlighting one or more indicator findings. Community Perspectives summarizes the input from the Healthy Montgomery Community Conversations series. Key Definitions presents definitions used in the Summary of Key Findings section. Please note that when the finding is based on responses to a question in the Maryland Behavioral Risk Factor Surveillance System (BRFSS), we have provided the wording of the question. Health Section Page 1 of 31 Draft Version: 7/29/2011

2 Data Sources Used lists the data sources that were used in the introductory paragraph and the Findings section. Data Gaps Identified lists data that would help us further understand the topic but are not currently available to us. Summary Measures of Health Life Expectancy Montgomery County experiences one of the highest life expectancies at birth both in Maryland and in the United States. Life expectancy at birth is the calculated estimate of the lifespan for an infant born in Montgomery County on a particular year based on the birth and death event patterns experienced by the overall population that year. In 2007, Montgomery County had the highest male and female life expectancies at birth compared to all other jurisdictions in Maryland. Montgomery County also has the 3 rd highest male life expectancy and the 5 th highest female life expectancy in the United States. In 2007, the average life expectancy at birth was 84.5 years for girls and 80.7 for boys. The life expectancy for Black females in Montgomery County MD was the highest in the nation (81.8 years) while life expectancy for Black males (77.0 years) was the second only to Fairfax County VA (77.2 years) in the U.S. For White females (84.7 years) and White males (84.5 years) Montgomery county was also ranked 2 nd nationally. Health Section Page 2 of 31 Draft Version: 7/29/2011

3 Life Expectancy at Birth, 1987 and 2007 By Gender and By Select Race Groups Life Expectancy in Years Total Male White Male Black Male Total Female White Female Black Female Leading Causes of Death Women The top three leading causes of death among women in Montgomery County in were major cardiovascular diseases (over 900 deaths a year), cancer (700 deaths a year) and chronic lower respiratory disease (100 deaths per year). Additionally about 100 women die each year in Montgomery County from Alzheimer s Disease. Females: All races, ethnicities, and ages combined Rate Per Cause Rank 100,000 Females Major Cardiovascular Diseases Malignant Neoplasms Chronic Lower Respiratory Diseases Influenza and Pneumonia Alzheimer's Disease Health Section Page 3 of 31 Draft Version: 7/29/2011

4 The leading causes among women vary by race and ethnicity. Among African American/Black women, the top three leading causes of death in were heart disease, cancer and diabetes. The top three leading causes for Asian/Pacific Islander women were cancer, heart disease, and chronic lower respiratory disease. For Hispanic/Latino women, the top three causes were heart disease, cancer and accidents. For White women, the top three causes were heart disease, cancer, and all chronic lower respiratory disease. The leading causes of death also vary across the lifespan: among females, years, the leading causes were accidents, suicide, and heart disease; for females, years, the leading causes were cancer, accidents, and complications due to pregnancy/childbirth; among year old women the leading causes were cancer, heart disease and accidents; and for females, years, the leading causes were cancer, heart disease and diabetes. Men The top three leading causes of death among men in Montgomery County in were major cardiovascular diseases (over 800 deaths a year), cancer (600 deaths a year) and accidents (107 deaths per year). Males: All races, ethnicities, and ages combined Rate Per Cause Rank 100,000 Males Major Cardiovascular Diseases Malignant Neoplasms Accidents Chronic Lower Respiratory Diseases Influenza and Pneumonia The leading causes among men vary little by race and ethnicity. Among African American/Black, Hispanic/Latino and White men, the top three leading causes of death in were heart disease, cancer, and accidents while the top three leading causes for Asian/Pacific Islander men were cancer, heart disease, and accidents. The leading causes of death do vary across the lifespan: among males aged years, the leading causes were accidents, homicide, and suicide; for males, ages years, the leading causes were accidents, heart disease and events of undetermined intent; among year old men the leading causes were heart disease, cancer and accidents; and for males, ages years, the leading causes were cancer, heart disease and diabetes. Health Section Page 4 of 31 Draft Version: 7/29/2011

5 Access to Health Services In 2009, over 110,000 residents (8,130 children and 102,154 adults) in Montgomery County reported that they had no current form of health insurance coverage; Montgomery County has the largest number of non citizen residents (64,488) with no health insurance among all the jurisdictions in Maryland (38% of the State s 169,701 non citizen residents with no health insurance). Almost 65% of the Montgomery County uninsured population comes from households with combined incomes of less than $75,000 annually. Health Insurance Status Among Montgomery County Residents, 2009 Total Males Females Insured Uninsured 0% 20% 40% 60% 80% 100% Summary of Key Data Findings Men and all young adults, years, are less likely than women to report having visited a doctor for a routine checkup within the last two years. One out of every 10 residents, one in every three Hispanic/Latino residents, one in every 30 children, and one in every eight adult males have no form of health insurance coverage. Children (< 18) Adults (18-24) Adults (25-64) Elderly (65+) Asian/PI One in every five adults (18 44 years), one in every four Hispanic/Latino adults, one in every six African American/Black adults, and one in every six adult males reported they were unable to see a doctor in the past year because they could not afford it. Black/AA Related Topics Hispanic While all health and well being topics in this report are not listed individually below, they White are all inextricably linked to access to timely and high quality health care. Additionally there are several social determinants linked that are listed below: Economy Income Poverty Employment Education Health Section Page 5 of 31 Draft Version: 7/29/2011

6 Community Perspectives Almost all Community Conversation groups ranked affordable/accessible health care as a priority. Concerns about poverty, employment, income, and transportation created anxiety about health care access. Inadequate access to health care (including mental health and dental health, both which came up repeatedly) for some populations was a concern among nearly all groups, but immigrant groups in particular. Latinos/Hispanics, Vietnamese, and Mandarin Chinese described limitations imposed by immigration status and language barriers as well as economics in accessing health care. Many participants expressed concern for the growing number of county residents who fell in the gap of being eligible for health care insurance but being unable to pay the premiums. In addition, reference was made to employers not providing benefits, particularly among immigrant groups, and the use of emergency care for routine health care. Key Definitions No health insurance coverage = persons who responded that they currently do not have any private (employer based, direct purchase, TRICARE or other military coverage) or public (Medicare, Medicaid, Medical Assistance, Children s Health Insurance Program or other state specific plan, VA Healthcare, or Indian Health Service) health insurance coverage in the past year. 1 Regular source of care = visited a doctor for a routine checkup within the last two years (routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition). 2 Data Sources Used American Community Survey, U.S. Census Bureau, 2009 Maryland Behavioral Risk Factor Surveillance System, 2009 Data Gaps Identified Health insurance coverage data are not available by geographic areas within Montgomery County. Health insurance coverage data are not available to evaluate coverage patterns within race/ethnicity by age gender specific subgroups. Immunizations & Infectious Diseases Control of communicable diseases (including infectious diseases) depends on prevention, diagnosis, and treatment, along with effective education, outreach, outbreak investigation and contact tracing. 1 U.S. Census Bureau. (2010). ACS health insurance definitions. U.S. Census Bureau, from 2 CDC. (July 1, 2010). Maryland Behavioral Risk Factor Surveillance System 2009 Codebook Report. Centers for Disease Control, from Health Section Page 6 of 31 Draft Version: 7/29/2011

7 Number of Montgomery County Residents Living with HIV by AIDS Status 3,500 3,000 2,500 2,000 According to the U.S. Centers for Disease Control and Prevention, Montgomery County exceeded the Healthy People 2020 target at baseline with 80.1% of children, ages months in , who had complete the recommended vaccination series. 3 1,500 Summary of Key Data Findings Montgomery County has a 1,000 lower rate of new cases (incidence) of HIV 4,5 500 than the Maryland average, which 0 includes Baltimore City and Prince Georges County, but remains almost double the national HIV incidence rate. In Montgomery County HIV related deaths decreased by 36% from to Almost four out of five HIV related deaths are African Chlamydia, Gonorrhea, and Syphilis Incidence Rates, Montgomery County, American/Black residents Living HIV Cases with AIDS Living HIV Cases without AIDS Sexually transmitted infection rates for Chlamydia and Gonorrhea 6 in Montgomery County are lower than most other Maryland jurisdictions while Syphilis incidence rates are about 50% higher than the median rate among the 24 Maryland jurisdictions. Montgomery County Syphilis incidence rates have dropped for the third straight year from 2.4 per 100,000 in 2007 to 2.1 in Rate Per 100,000 Population Chlamydia Gonorrhea Syphilis CDC. (April 29, 2011). County level trends in vaccination coverage among children Aged months United States, Morbidity and Mortality Weekly Report, Surveillance Summaries, 60(4), from 4 Infectious Disease and Environmental Health Administration. (2011). Monitoring, Reporting, and Evaluation. Maryland Department of Health and Mental Hygiene, from reportoring andevaluation.aspx. 5 Schneider, E., Whitmore, S., Glynn, M.K., Dominguez, K., Mitsch, A., Mckenna, M.T. (December 5, 2008). Revised surveillance case definitions for HIV infection among adults, adolescents, and children aged <18 months and for HIV infection and AIDS among children aged 18 months to <13 years United States, CDC, Morbidity and Mortality Weekly Report 57(RR10): 1 8, from 6 Infectious Disease and Environmental Health Administration (2009). STI Data and Statistics. Maryland Department of Health and Mental Hygiene, from data statistics.aspx. Health Section Page 7 of 31 Draft Version: 7/29/2011

8 Senior vaccination rates for pneumonia and influenza are lower among younger seniors, years, than for those 85 years and older. Senior men are less likely to be vaccinated compared to senior women. Deaths due to either influenza or pneumonia are higher among men and deaths occur mostly among seniors, 65 years and older. White senior adults experience 45% higher rates of death than Asian/Pacific Islander seniors and 10% higher rates than African American/Black seniors. Related Topics Access to Health Services Cancer (Cervical HPV) Respiratory Diseases Key Definitions Complete vaccination series = four or more doses of diphtheria, tetanus and acellular pertussis or diphtheria, tetanus, pertussis (DTaP/DTP); three or more doses of polio vaccine, one or more doses of measles, mumps, rubella (MMR) vaccine; three or more doses of Haemophilus influenzae type B (Hib) vaccine; three or more doses of hepatitis B vaccine; one or more doses of varicella vaccine; and four or more doses of 7 valent pneumococcal conjugate vaccine (PCV7) for children 19 to 36 months. 7 Senior vaccination rates for pneumonia= Adults 65 years and older who report ever having a pneumococcal vaccine Senior vaccination rates for influenza= Adults 65 years and older who report having an influenza vaccine in the past year Data Sources Used Family Health Administration, Maryland Department of Health and Mental Hygiene, 2009 Maryland Behavioral Risk Factor Surveillance System, 2009 National Immunization Survey, U.S. Centers for Disease Control and Prevention, 2009 Data Gaps Identified More detailed data are needed for each type of communicable/sexually transmitted disease to enable comparisons within race/ethnicity subgroups by both age and gender. County wide data on children that characterize important health status and heath risk behaviors, such as vaccination status, STD and HIV education, are not available. This a group that has an increasing risk for many health conditions in childhood and adulthood. The State plans to field the Youth Risk Behavior Surveillance System (YRBSS) at the County level biannually, beginning in the fall of This should address the data gap for older children/adolescents if reproductive and sexual health questions are included. 7 CDC. (April 29, 2011). County level trends in vaccination coverage among children Aged months United States, Morbidity and Mortality Weekly Report, Surveillance Summaries, 60(4), from Health Section Page 8 of 31 Draft Version: 7/29/2011

9 Health risk behaviors that increase the risk for many health conditions including HIV and other sexually transmitted infections are difficult to measure accurately among our sub populations, especially the Hispanic/Latino populations because of survey methodology issues. Cancer The group of diseases collectively known as cancer was the top leading cause of death among Montgomery County Asians and Pacific Islanders and is the second leading cause of death among all other residents. The burden of battling cancers within our community varies, with disparities clearly present. Summary of Key Data Findings While more White women are diagnosed with breast cancer every year, 50% more African American/Black women die from breast cancer than White women. Non Hispanic White women and Asian/Pacific Islander women had breast cancer death rates in that met the Healthy People 2010 target (22.3 deaths per 100,000 women) while Black and African American women had a death rate (30.2) that was 1.5 times the White rate (19.9) and 3 times the Asian/Pacific Islander rate (8.0). Hispanic/Latino women are diagnosed with cervical cancer about twice as often as other women. Colorectal cancer screening is low among all men. African Americans/Blacks have the lowest screening rates and they are also most likely to be diagnosed with or die from colorectal cancer when compared to the rates of Whites, Asians or Pacific Islanders and Hispanic/Latinos. Lung and bronchus cancer incidence is higher among men than women, with White and African American/Black residents twice as likely as Asians or Pacific Islanders to be diagnosed. African American/Black men are 50% more likely to be diagnosed with prostate cancer and are twice as likely as White men to die from the disease. Health Section Page 9 of 31 Draft Version: 7/29/2011

10 Related Topics Access to Health Services Immunizations & Infectious Diseases (HPV) Maternal, Infant and Child Health Family Planning Exercise, Nutrition and Weight Substance Abuse (Tobacco Use) Montgomery County Prostate Cancer Incidence and Mortality among Black/African American, Hispanic, and White Males, Total Black/AA Prostate Cancer Incidence Rate Prostate Cancer Mortality Rate Rate Per 100,000 Males Key Definitions Hispanic Cancer incidence = the number of new cancers White of a specific site/type occurring in a specified population during a year, usually expressed as the number of cancers per 100,000 population at risk. 8 Data Sources Used State and County Cancer Profiles, National Cancer Institute, National Institutes for Health and the Centers for Disease Control and Prevention (statecancerprofiles.cancer.gov), 2009 Maryland Behavioral Risk Factor Surveillance System, 2009 Data Gaps Identified Cancer screening, incidence and mortality data are not available by geographic areas within Montgomery County. Cancer screening, incidence and mortality data are not available to evaluate patterns within race/ethnicity by age gender specific subgroups. 8 SEER. (2011). Cancer Incident Rates. NCI, from Health Section Page 10 of 31 Draft Version: 7/29/2011

11 Chronic Diseases Diabetes Healthy Montgomery Community Health Improvement Process More than 135 Montgomery County residents die from diabetes annually. Diabetes is the eighth overall leading cause of death among Montgomery County residents. It ranks as the fourth leading cause of death among African Americans/Blacks, fifth leading cause of death among Hispanics/Latinos, and sixth leading cause of death among Asians and Pacific Islanders. Diabetes Prevalence and Mortality in Montgomery County by Gender, Age, and Race/Ethnicity 0% 5% 10% 15% 20% Total % Diabetes Prevalence (%) Males Females % % Diabetes Mortality (Rate Per 100,000) Adults (18-44) Adults (45-64) Elderly (65+) % 8.3% 16.6% 91.7 Black/AA Asian/PI Hispanic White 0.3% % 8.9% 16.3% Rate Per 100,000 Population Summary of Key Data Findings Men are more likely than women to report ever being diagnosed with diabetes by their doctor and also experience a higher diabetes mortality rate. Diabetes mortality in the elderly (91.7 per 100,000) is significantly higher than both adults younger than 65 (7.4 per 100,000). Health Section Page 11 of 31 Draft Version: 7/29/2011

12 One out of every six African American/Black adults report ever being diagnosed with diabetes. African American/Black residents have a mortality rate that is more than twice the overall County rate. Related Topics Access to Health Services Heart Disease and Stroke Exercise Nutrition and Weight Wellness and Lifestyle Maternal Fetal and Infant Death Mental Health and Mental Disorders Key Definitions Diabetes = Person who responded that he/she was ever been told by a doctor that he/she has diabetes (excludes pre diabetes, borderline diabetes and females who reported the diagnosis was only when she was pregnant) 9 Data Sources Used Maryland Behavioral Risk Factor Surveillance System, 2009 Data Gaps Identified Diabetes prevalence is not available for children, a group that has had an increasing risk for type 2 diabetes in recent years due to increasing overweight/obesity rates. Data about health risk (lifestyle) behaviors that contribute to the onset of diabetes are also not available for Montgomery County children. The State plans to field the Youth Risk Behavior Surveillance System (YRBSS) at the County level biannually, beginning in the fall of This should address the data gap for older children/adolescents. Health risk behaviors that increase the risk for developing diabetes are difficult to measure accurately in our subpopulations, especially the Hispanic/Latino populations, due to BRFSS methodology issues. Heart Disease and Stroke Major cardiovascular disease is the leading cause of death among all County residents. It is the leading cause of death for African American/Black, Hispanic/Latino and White residents and is the second leading cause of death among Asian and Pacific Islander residents. High blood pressure and high cholesterol both contribute to an increased prevalence of heart disease and stroke. 9 CDC. (July 1, 2010). Maryland Behavioral Risk Factor Surveillance System 2009 Codebook Report. Centers for Disease Control, from Health Section Page 12 of 31 Draft Version: 7/29/2011

13 Summary of Key Data Findings African American/Black residents die from stroke (cerebrovascular disease) at a rate (34.4 deaths per 100,000 population) that is 15% higher than White residents (29.8 per 100,000 population) and more than double the rate experienced by Hispanic/Latino residents (14.5 per 100,000 population). The heart disease mortality rate among men (167.5 deaths per 100,000 population) is over 50% higher than it is for women (106.2 per 100,000 population); African American/Black residents experience a mortality rate (159.5 per 100,000 population) that is three times the rate of Hispanic/Latino residents (53.9 per 100,000 population) and more than double the rate experienced by Asians and Pacific Islanders (71.7 per 100,000 population). About one out of every four adults (ages 18 64) has high blood pressure (hypertension). Approximately three out of ten adult men are hypertensive. This likelihood increases with age such that one out of every two seniors, 65 years and older, has hypertension. African American /Black adult residents are approximately one and a half times more likely (39.9%) than White residents (24.6%), twice as likely as Asian/Pacific Islander residents (17.1%) and three times more likely than Hispanic/Latino residents (14.4%) to experience high blood pressure. Rates of high cholesterol have increased in the County from 30% in 2005 to 39% in More than half of seniors have high cholesterol levels, which is a major risk factor for heart disease. Four in ten men have high cholesterol compared to three in ten women. Almost half (46.2%) of Asian and Pacific Islander adults have high cholesterol a prevalence rate that is two thirds higher than Hispanic/Latino residents (27.8%). Related Topics Access to Health Services Diabetes Mental Health and Mental Disorders Exercise Nutrition and Weight Wellness and Lifestyle Maternal Fetal and Infant Death Prevalence of High Blood Cholesterol and High Blood Pressure Among Montgomery County Adults, 2009 Total Males Females Adults (18-44) Adults (45-64) Elderly (65+) Black/AA Asian/PI Hispanic White High Blood Pressure High Cholesterol 0% 10% 20% 30% 40% 50% 60% 11% 14% 17% 22% 25% 27% 27% 29% 28% 25% 34% 39% 40% 37% 41% 44% 45% 46% 55% 53% Health Section Page 13 of 31 Draft Version: 7/29/2011

14 Key Definitions Heart disease deaths= death due to acute myocardial infarction, other ischemic heart disease, hypertensive heart disease, heart failure and all other heart disease (International Classification of Diseases (ICD) 10 codes I00 I09,I11,I13,I20 I51) as the underlying cause of death among residents during a calendar year) Cerebrovascular disease deaths= Deaths with International Classification of Diseases (ICD) 10 codes I60 I69 (ICD 9 code ) as the underlying cause of death among residents during a calendar year 10 High blood pressure (hypertension)= Adults 18 years and older who report having been told by a doctor, nurse, or other health professional of having high blood pressure 11 High cholesterol= Adults 18 years and older who report having been told by a doctor or health professional that your blood cholesterol is high 12 Data Sources Used Vital Statistics Administration, Maryland Department of Health and Mental Hygiene, 2009 Maryland Behavioral Risk Factor Surveillance System, 2009 Data Gaps Identified County wide data that characterize important health risk and lifestyle behaviors like nutrition, exercise, and sedentary behaviors are not available for children, a group that has an increasing risk for many health conditions in childhood and adulthood. With the anticipated rollout of the YRBS at the county level expected to begin biannual data collection in the Fall of 2012, this gap should be addressed for older children/adolescents. Health risk behaviors that increase the risk for many chronic health conditions like diabetes, cancer and heart disease are difficult to measure accurately among our sub populations, especially the Hispanic/Latino populations because of survey methodology limitations. 10 CDC. (2008). Chronic disease indicators: indicator definitions. Center for Disease Control, from 11 CDC. (2008). Chronic disease indicators: indicator definitions. Center for Disease Control, from Health Section Page 14 of 31 Draft Version: 7/29/2011

15 Respiratory Diseases Healthy Montgomery Community Health Improvement Process The National Capital Region has received a failing letter grade of F on air quality, 12 according to the American Lung Association index that bases its grades on the annual number of days that ozone levels exceed U.S. standards. Thus, air quality clearly remains a challenge for respiratory health in Montgomery County and contributes to the asthma prevalence in our population. According to the 2009 Maryland Behavioral Risk Factor Surveillance System, almost 17% of children, ages 2 18 years, have been diagnosed with asthma. Hispanic/Latino children have a higher asthma prevalence (14% in ) compared to other racial/ethnic groups. Prevalence of Asthma Among Montgomery County Adults, 2009 Total Male Female Adults (18-44) Adults (45-64) Elderly (65+) African American Asian/PI Hispanic White With Health Insurance No Health Insurance Unemployed Students/ Homemakers (Influenza and Pneumonia) Access to Health Services 0% 5% 10% 15% 20% 12% 11% 14% 14% 11% 13% 12% 10% 10% 13% 17% 16% 14% 17% Summary of Key Data Findings In , 12.5% of adults reported being diagnosed with asthma. Women (13.6%) have higher reported prevalence rates than men (11.2%). There is a higher reported asthma prevalence rate among Hispanic/Latino adults (17.5%) as compared to other racial/ethnic groups. Adults that reported having any kind of health insurance coverage had higher asthma prevalence (13.6%) than those not covered (9.5%). Unemployed adults (21.5%) and students/homemakers (17.3%) have a higher prevalence of asthma than the overall adult population. Unmarried adults have a significantly higher prevalence of asthma (16.4%) than married adults (11.1%). Older adults have the highest mortality rates due to chronic lower respiratory diseases, with Whites having the highest rates among racial/ethnic groups. Related Topics Immunizations & Infectious Diseases 12 American Lung Association (2011). State of the Air Retrieved on May 3, 2011, from ( html ). Health Section Page 15 of 31 Draft Version: 7/29/2011

16 Key Definitions Chronic lower respiratory disease death rate= the number of deaths classified as ICD 10 codes J40 J47, excluding cystic fibrosis, and including bronchitis, emphysema, MacLeod's syndrome, other chronic obstructive pulmonary disease, asthma, and bronchiectasis. Data Sources Used Vital Statistics Administration, Maryland Department of Health and Mental Hygiene, 2009 Maryland Behavioral Risk Factor Surveillance System, 2009 Data Gaps Identified County wide data that characterize important health status, health risk and lifestyle behaviors, such as quality of life measures, overall mental and physical health and well being, violence, stress, bullying, substance abuse, physical activity, nutrition, and sedentary behaviors, are not available for children, a group that has an increasing risk for many health and mental health conditions either in childhood or later in adulthood. The State plans to field the Youth Risk Behavior Surveillance System (YRBSS) at the County level biannually, beginning in the fall of This should address the data gap for older children/adolescents. Health status, health risk and lifestyle behaviors, such as quality of life measures, overall mental and physical health and well being, violence, substance abuse, physical activity, nutrition, and sedentary behaviors that increase the risk for developing mental health and chronic health conditions, such as depression, anxiety disorders, diabetes, cancer and heart disease, are difficult to measure accurately among our sub populations, especially the Hispanic/Latino and Asian/Pacific Islander subpopulations because of survey methodology issues. Utilization data on ER and admissions due to asthma were not available for evaluation at the time this report was compiled. Data on young children and impact of environment on their health are not available. Healthy Living and Disease Prevention Wellness and Lifestyle Wellness and lifestyle can be measured through a number of different summary measures of health and wellbeing from individual self evaluation of health and mental health status to population based death rates, life expectancy to broader composite quality of life indices. As an entire population, Montgomery County experienced one of the highest life expectancies the average number of years a baby born in can expect to live from birth in the National Capital Region. Further analysis is needed to identify disparities across the diverse communities that now reside in Montgomery County and that reflect the most current data available. Health Section Page 16 of 31 Draft Version: 7/29/2011

17 Self-Reported Wellness Among Montgomery County Residents, 2009 General Health Being Good/Very Good/Excellent Satisfied/Very Satisfied with Life Good Physical Health 0% 20% 40% 60% 80% 100% 120% Total 76% 89% 95% Males Females 89% 95% 79% 89% 95% 75% Adults (18-44) Adults (45-64) Elderly (65+) 90% 95% 78% 87% 94% 76% 91% 97% 74% Black/AA Asian/PI Hispanic White 77% 73% 75% 74% 76% 90% 88% 96% 99% 99% 90% 94% Su Health Section Page 17 of 31 Draft Version: 7/29/2011

18 Summary of Key Data Findings Adults, ages years, had the lowest self reported general health being good, very good or excellent (87%) compared to other ages. Hispanic/Latino adults reported the lowest percent of being in good, very good general health (75%) compared to the other racial/ethnic groups; Asian and Pacific Islander adults had the highest at 96%. Both Asian/ Pacific Islander and Hispanic/Latino adults had the highest self reported life satisfaction (both were 99%) compared to other racial ethnic groups. African American/Black adults had the lowest percent (88%). Seniors, aged 65 and older, had the highest self reported life satisfaction (97%) compared to all other adults. Women are less likely to report being in good physical health (75%) than men (79%). Fewer seniors (73.9%), Asian/Pacific Islander adults (73%) and Hispanic/Latino adults (74%) reported being in good physical health than the total Montgomery County population (76%). Related Topics Access to Health Services Exercise, Nutrition and Weight Mental Health and Mental Disorders Social Environment Key Definitions Self reported general health = Percent of adults who responded good, very good, or excellent to the question How is your general health? Self reported physical health = Percent of adults who reported 2 or fewer days in the past 30 days that their physical health was not good Self reported life satisfaction = percent of adults who answered that they are very satisfied or satisfied when asked, "In general, how satisfied are you with your life?" Data Sources Used Maryland Behavioral Risk Factor Surveillance System, 2009 Data Gaps Identified County wide data that characterize important health risk and lifestyle behaviors like nutrition, exercise, and sedentary behaviors are not available for children, a group that has an increasing risk for many health conditions in childhood and adulthood. With the anticipated rollout of the YRBS at the county level expected to begin biannual data collection in the Fall of 2012, this gap should be addressed for older children/adolescents. Health risk behaviors that increase the risk for many chronic health conditions like diabetes, cancer and heart disease are difficult to measure accurately among our sub populations, especially the Hispanic/Latino populations because of survey methodology limitations. There is a need for better summary measures of health and well being and annual life expectancy by gender, race, and ethnicity Health Section Page 18 of 31 Draft Version: 7/29/2011

19 Exercise, Nutrition & Weight In 2009, Montgomery County had more adults that consume five or more fruits and vegetables daily compared to all other reporting areas in Maryland. Montgomery County also has a statistically significant higher proportion of adults (48.4%) who are not overweight or obese compared with the rest of Maryland. Montgomery County has the lowest proportion of obese adults (17.5%) compared to the rest of the State (26.8%). Montgomery County is comparable (33.9%) to the Maryland average (34.1%) in the percent of adults with low to moderate physical activity on a weekly basis. Summary of Key Findings Men are less likely to eat five or more fruits and vegetables daily (26.1%) than females (38.1%). Younger adults, ages (30.7%) and adults, ages (30.0%) are less likely to get the recommended servings of fruits and vegetables than the elderly (39.7%). White adults were most likely to get five or more servings (33.6%) when compared to Asians (27.3%), African Americans/Blacks (29.1%) and Hispanic/Latinos (30.4%). Men are less likely to engage in at least light to moderate physical activity than females. Adults, years (32.6%), are less likely to engage in at least light tomoderate physical activity than adults years (34.4%) or the elderly (35.1%). Hispanic/Latino adults (39.7%) and White adults (35.2%) are more likely than Asian/Pacific Islander (25.3%) and African American/Black (29.1%) adults to engage in at least lightto moderate physical activity. Men (61.0%) are more likely to be at least overweight than females (41.9%). Seven out of every ten Hispanic/Latino adults and African American/Black adults are either overweight or obese. Obesity levels are lowest among the Asian/Pacific Islander adults (2.6%) and highest among African American/Black (28%) and Hispanic/Latino adults (30%). Weight Status Among Montgomery County Residents, 2009 Normal Weight Overweight Obese Total Males Females Children (under 18) Adults Elderly African American Asian/PI Hispanic White 0% 20% 40% 60% 80% 100% Health Section Page 19 of 31 Draft Version: 7/29/2011

20 Related Topics Access to Health Services Cancer Diabetes Heart Disease and Stroke Maternal, Infant and Child Health Mental Health and Mental Disorders Prevention and Safety Community Perspectives Physical education in schools Insufficient emphasis on and quality of physical education in the schools came up frequently. Youth reported that P.E. was optional past the first year and did not inspire participation or further exercise. Adults, including seniors, expressed concern over the inadequacy of P.E. for young people, and the effects this might have on obesity and future risk of chronic disease. A frequent suggestion across groups was the need for more physical education classes/activities and more health education in schools. Healthy eating Healthy diet and exercise were concerns that arose in numerous groups. Common themes included the need to maintain or increase access to fresh fruits and vegetables, the need for more education about healthy eating and healthy lifestyles for all age groups (including youth and seniors), and the need to address the prevalence of junk food in schools and the overall poor nutritional value of school lunches. Youth in Germantown were in agreement that the food in the school system was of poor quality and that junk food was readily available. Key Definitions At least light/moderate physical activity= adults that reported doing 30 or more minutes per day and for five or more days per week of moderate physical activity or 20 or more minutes per day and three or more days per week of vigorous physical activity 13 Overweight or Obese adult = Respondents aged >=18 years who have a body mass index that meets the criteria listed below. 14 o An adult who has a BMI between 25 and 29.9 is considered overweight. o An adult who has a BMI of 30 or higher is considered obese. See the following example: 13 Behavioral Risk Factor Surveillance System. (August 31, 2010). Calculated Variables. CDC, from 14 CDC. (2008). Chronic disease indicators: indicator definitions. Center for Disease Control, from Health Section Page 20 of 31 Draft Version: 7/29/2011

21 Height Weight Range BMI Considered 124 lbs or less Below 18.5 Underweight 125 lbs to 168 lbs 18.5 to 24.9 Normal weight 5' 9" 169 lbs to 202 lbs 25.0 to 29.9 Overweight 203 lbs or more 30 or higher Obese Data Sources Used Maryland Behavioral Risk Factor Surveillance System, 2009 Data Gaps Identified County wide data that characterize health risk and lifestyle behaviors like nutrition, exercise, and sedentary behaviors are not available for children 15, a group that has an increasing risk for many health conditions in childhood and adulthood. The State plans to field the Youth Risk Behavior Surveillance System (YRBSS) at the County level biannually, beginning in the fall of This should address the data gap for older children/adolescents. Health risk behaviors that increase the risk for many chronic health conditions, such as diabetes, cancer and heart disease, are difficult to measure accurately among our sub populations, especially the Hispanic/Latino populations due to survey methodology issues. Prevention and Safety In 2009, almost 84% of Maryland adolescents rarely or never wore a bicycle helmet. One in 12 adolescents rarely or never wore a seatbelt. Over 25% of adolescents had ridden in a car with someone who had been drinking. Seven percent of Maryland teens did not go to school because they felt unsafe. Almost one in ten Maryland students reported being threatened while at school. Summary of Key Data Findings The unintentional injury death rate 16 is two fold higher for males than females. Older adults (65 years and older) experience the highest rates, more than twice the rate for all ages. The pedestrian fatality rate 17 per 100,000 population in Montgomery County decreased by almost 50% (from 1.7 to 0.9, respectively) from 2007 to The BRFSS asked adults to report height and weight for children in the household. Their responses indicate that almost one third (29.5%) of all children under the age of 18 in the County are overweight or obese. 16 Unintentional injury death rate is the age adjusted rate of deaths classified with (ICD 10) codes V01 X59, Y85 Y86 in the past calendar year per 100,000 population. 17 U.S. Department of Transportation. (2009). Traffic Safety Facts for Maryland : Pedestrian Fatalities. National Highway Traffic Safety Administration, from nrd.nhtsa.dot.gov/departments/nrd 30/ncsa/STSI/24_MD/2009/Maryland_Map_16_DATA_2009.PDF. Health Section Page 21 of 31 Draft Version: 7/29/2011

22 Related Topics Exercise, Nutrition and Weight Substance Abuse Mental Health and Mental Disorders Age-Specific Rate (Unadjusted) Community Perspectives Unintentional Injury Deaths Among Montgomery County Residents, Age-Adjusted Rate Per 100,000 Residents expressed frustration with the lack of walk able and bike able neighborhoods and communities. Outside of the bike trails through parks, walking and biking was generally viewed Total 17.7 as unsafe and not practical as a means of everyday transportation. Up county residents were particularly Male 24.8 concerned with traffic safety related to Female 11.7 the increased urban/suburban sprawl. In addition, youth expressed concerns Young Adults (15-24) Adults (25-34) Adults (35-44) Adults (45-54) Older Adults (55-64) Elderly (65-74) about violence and bullying in community schools. At the same time, while they viewed informal gangs, bullying, and fighting as problems, youth also reported they generally felt safe in their school and neighborhood. Elderly (75-84) 68.0 Some participants in immigrant groups Elderly reported not feeling secure because their immigration status could preclude Black/AA 17.2 reporting crimes to police (e.g., providing Asian/PI 13.0 proof of residence). There were Hispanic 15.5 recommendations regarding the need for effective police/community interaction White 17.6 and accountability, better lighting, and gun control. Residents identified access to information about prevention and maintaining healthy lifestyles as an important priority in many Community Conversations. Residents were not necessarily suggesting that this information was not already available, but simply stated that it should be a high priority. Data Sources Used Fatal Analysis Reporting System, U. S. National Highway Traffic and Safety Administration, 2009 Vital Statistics Administration, Maryland Department of Health and Mental Hygiene, 2009 Health Section Page 22 of 31 Draft Version: 7/29/2011

23 Data Gaps Identified: County wide data that characterize health risk and lifestyle behaviors, such as safety, prevention, and protective behaviors are not available for Montgomery County adolescents or children groups that have an increasing risk for many poor health outcomes in childhood and adulthood. The State plans to field the Youth Risk Behavior Surveillance System (YRBSS) at the County level biannually, beginning in the fall of This should address the data gap for older children/adolescents if prevention and safety related questions are included. Health risk (lifestyle) behaviors are difficult to measure accurately among our sub populations, especially the Hispanic/Latino populations because of survey methodology issues. Maternal, Infant and Child Health Maternal, Fetal and Infant Health Between 2001 and 2009, Montgomery County had significantly lower rates than Maryland overall for the percent of expectant mothers who smoked within the three months before pregnancy, engaged in binge drinking within three months before pregnancy, or were obese. 18 In , approximately 93% of Montgomery County mothers initiated breastfeeding after delivery. This was the highest rate among Maryland jurisdictions and exceeded the Healthy People 2020 Target (75%) and the Maryland average (78%). Montgomery County also met the 2020 target of 70% for placing infants on their backs to sleep 71% of Montgomery County infants were placed on their back to sleep. 18 However, there are opportunities to improve maternity care processes and outcomes within subpopulations in the County. Summary of Key Data Findings Teen mothers and mothers under 25 years of age are most likely not to have entered care within their first trimester. Only 67% of Hispanic/Latino mothers and 76.2% of African American/Black mothers entered care in their first trimester in 2009, both below the Healthy People 2020 target of 77.9%, and lower than White mothers (80.6%). 18 Maryland PRAMS. (February 2011). Focus on perinatal factors in Maryland counties and Baltimore City. Maryland Department of Health and Mental Hygiene, Family Health Administration. Retrieved on March 14, 2011, from Health Section Page 23 of 31 Draft Version: 7/29/2011

24 Teen mothers and mothers under 25 years of age are most likely to enter prenatal care late or get no prenatal care. In 2009 about 7% of Hispanic/Latino mothers and African American/Black mothers had no prenatal care or entered Entry of Mother into Prenatal Care Among Montgomery County Births, Total (15-17) (18-19) (20-24) (25-29) (30-34) (35-39) (40-44) Black/AA Asian/PI Hispanic White Early Prenatal Care 2nd Trimester Prenatal Care Late or No Prenatal Care 0% 20% 40% 60% 80% 100% care in their last trimester. The percent of mothers who received late or no prenatal care increased in 2009 for the first time in the past four years, from 3.12% in 2008 to 4.6% in The rates of low birth weight (LBW) and very low birth weight (VLBW) births are highest among African American/Black births. Montgomery County met the Healthy People 2020 LBW target of 7.8% in However, the percent of LBW births increased in 2009 to 8.2%. The percent of VLBW births remained at 1.4%, which equals the Healthy People 2020 target. Montgomery County has an infant death rate that is comparable to the median value (5.5 deaths per 1,000 live births) of all 24 Maryland jurisdictions. While the overall County infant mortality rate meets the Healthy People 2020 target of 6.0 per 1,000 live births, the African American/Black infant mortality rate at 10.7 deaths per 1,000 live births is almost double the County rate. Related Topics Family Planning Exercise, Nutrition, and Weight Mental Health and Mental Disorders (Depression) Diabetes Heart Disease and Stroke (Hypertension) Cancer (Breast, Cervical, Uterine, Ovarian) Health Section Page 24 of 31 Draft Version: 7/29/2011

25 Key Definitions Low birth weight birth = Birth of a baby with a weight of less than 2500 grams (up to and including 2499 grams), irrespective of gestational age 19 Very low birth weight birth = Birth of a baby with a weight of less than 1500 grams (up to and including 1499 grams), irrespective of gestational age 19 Infant mortality rate = Number of infant deaths per 1,000 live births 20 Infant death = Death of an infant before his or her first birthday 20 Teen birth rate = Number of births to females years per 1,000 females years Data Sources Used Vital Statistics Administration, Maryland Department of Health and Mental Hygiene, 2009 Maryland Behavioral Risk Factor Surveillance System, 2009 Data Gaps Identified Analysis of linked birth death records in Montgomery County would provide detailed information about characteristics and risk factors that contribute to fetal and infant losses in Montgomery County among those populations that could be at elevated risk for poor birth outcomes. An ongoing source of Pregnancy Risk Assessment Monitoring System (PRAMS) data at the County level at least every three years would improve policy and planning efforts in maternal, fetal and infant health. Family Planning 21 This section focuses principally on the topic of pregnancy. Related family planning/reproductive health topics are covered in the other sections of this report (including Cancer, Immunizations and Infectious Diseases, and Maternal, Fetal, and Infant Health). According to the Brookings Institute, the average cost of a publicly funded pregnancy is $7,100; it is likely that privately funded pregnancies are more costly due to the higher reimbursement to physicians and hospitals paid by private insurance. 22 Because almost half of all pregnancies are unintended, the 19 WHO (2011). WHO Statistical Information System: Low birth weight newborns (percentage). World Health Organization, from 20 CDC. (October, 2008). Publication and Information Briefs: NCHS data brief #9. Centers for Disease Control, from 21 Family planning includes breast and cervical cancer screening, contraceptive and other reproductive health services, sexually transmitted infections (STIs) services and pregnancy. This section focuses principally on the topic of pregnancy. Other topics are covered in the other sections of this report. 22 Monea, E., Thomas, A. (June 2011). Unintended pregnancy and taxpayer spending. Perspectives on Sexual and Reproductive Health 43(2): Retrieved on June 13, 2011, from Health Section Page 25 of 31 Draft Version: 7/29/2011