E R I M P R O V E T H G E I N H E S T O R O F A N S T H E K L A H M A B O

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1 S O L U I O N S : W O R K I N G O G E H E R O I M P R O V E H E S E O F H E S E S H E L H N O K L H O M S E B O R D O F H E L H R E P O R

2 Contents Introduction...1 Health Status Indicators...2 Underlying Causes...7 Solutions Conclusion Board of Health W O R K I N G O G E H E R O I M P R O V E

3 Introduction he State Board of Health presents its fourth annual State of the State s Health report to the citizens of Oklahoma. Our first report in 1997 provided a snapshot of the state s health. Unfortunately, we compared poorly to the rest of the nation. he 1998 report found considerable regional differences in health status. he data revealed that we have been losing ground compared to the rest of the nation, especially in the last decade. he third report in 1999 examined public health indicator trends and focused on critical issues related to the health of our younger population. lthough we reported some positive progress in certain areas, such as decreasing death rates over time for heart attacks, perinatal conditions, unintentional injuries, and birth defects, our improvement did not match the United States as a whole. Furthermore, we were alarmed by significant problems among our youth, including high rates of tobacco addiction, motor vehicle crashes, suicide, and teen pregnancy. We concluded with a proposed action agenda and stated, he Board of Health and the Oklahoma State Department of Health cannot improve current health conditions alone. Interventions will have to be initiated one step at a time, and most often by local communities, neighborhoods, and families. his 2000 report represents a departure from our first three reports. While we continue to examine health data trends, we will focus particularly on solutions. We are at a turning point in Oklahoma s future health and well-being. Unless we act together, now, with a planned approach, we may be unable to reverse the 1 trends of poor health we have been experiencing as a state. Physicians, public health professionals, business leaders, state government, our faith communities, and others simply must work together. Coordinated prevention activities must be our top priority. H E S E O F H E S E S H E L H

4 Health Status Indicators Behavioral Risk Factors Oklahoma s smoking rate continues to be higher than the national average. In 1998, the Centers for Disease Control and Prevention (CDC) reported through the Oklahoma Behavioral Risk Factor Surveillance System (BRFSS) that Oklahoma s adult smoking rate was 23.8 percent compared to a national median of 22.9 percent. Even more distressing is the fact that Oklahomans who smoke consume more cigarettes than much of the nation, packs per capita compared to 86.9 packs per capita for the U.S. (CDC, State obacco Control Highlights, 1999). In addition, 42 percent of our high school students are currently at risk for lifelong nicotine addiction, a rate considerably higher than the rest of the nation. Until our state leaders seriously consider the impact smoking has on the health of our citizens and act accordingly, we will continue to see high rates of lung cancer, emphysema, heart disease, stroke, and other conditions directly related to this addiction. ppropriate use of tobacco settlement funds can make a powerful impact on improving the health of Oklahomans. If not, the burden of tobacco use will continue to plague our citizens disproportionately compared to the U.S. as a whole. Figure 1 Behavioral Risk Factors, US & Oklahoma, 1998 lack of seat belt use US Oklahoma lack of exercise overweight smoking 0% 20% 40% 60% 80% 100% W O R K I N G O G E H E R O I M P R O V E

5 nother risk factor of concern is overweight. In 1998, CDC, through the BRFSS, reported that 32.4 percent of Oklahomans were at risk for health problems related to being overweight, again higher than the nation. his may be in part due to lack of exercise. ccording to CDC, 84.3 percent of Oklahomans are at risk for health problems related to lack of regular and sustained physical activity compared to a national average of 79.7 percent. his combined effect of overweight and lack of exercise puts far too many of our citizens at risk for serious conditions, such as high blood pressure, stroke, heart disease, type 2 diabetes, and osteoarthritis. Motor vehicle crashes continue to be the leading cause of injury death in Oklahoma. Oklahoma s age adjusted death rate for motor vehicle injuries is 24 per 100,000 compared to 16.2 per 100,000 for the U.S. (CDC, Oklahoma State Health Profile, 1999). lthough Oklahoma s seat belt use has increased over the years, we still lag behind the rest of the nation. In 1997, our rate for lack of seat belt use was 36.9 percent compared to a national rate of 30.8 percent (Oklahoma BRFSS). Oklahoma has a high percentage (50 percent) of firearms available in its homes. Easy access to firearms may in part explain Oklahoma s gun-related homicides and suicides. nother concern is our high rate of unwanted pregnancies. For several years in 3 a row, the data have shown that a child born as a result of an unwanted birth is much more likely to be at risk for numerous health problems, including child abuse. hree-quarters of our births to teens are unintended. Chances for these children living in poverty are three times greater than for mothers who delay childbearing until after the age of 20. H E S E O F H E S E S H E L H

6 Figure 2 ge djusted Death Rates for ll Causes, US & Oklahoma rate per 100, US Oklahoma Leading Causes of Death s seen in the 1999 State of the State s Health report, Oklahoma s leading causes of death are heart disease, cancers, injuries, stroke, and chronic obstructive pulmonary disease. Unfortunately, Oklahomans die from these causes at a higher rate than the rest of the nation. aking all causes of death into account, Oklahoma s 1998 age-adjusted death rate per 100,000 population was compared to a national average of (CDC, National Vital Statistics Report, 10/5/99). his 11.3 percent higher rate is absolutely unacceptable. Because of our high death rates, we have far too many years of productive lives being lost in Oklahoma (CDC, Oklahoma State Health Profile, 1999). lso, as described in our 1999 report, we are concerned about the differences we see in death rates within our state. hese differences are evident geographically, where one county with low death rates may be next to a county with high death rates. Striking differences are also seen among race and gender groups in Oklahoma (CDC, Oklahoma State Health Profile, 1999). Why such differences? W O R K I N G O G E H E R O I M P R O V E

7 Figure 3 ge djusted Death Rates per 100,000 Population, US & Oklahoma heart disease cancer injuries stroke copd US White Black merican sian Hispanic Indian 5 H E S E O F H E S E S H E L H

8 Figure 4 ge djusted Years of Potential Life Lost Before ge 75 per 100,000 Population 8,632 US 7,743 8,368-18,478 7,584-8,299 6,550-7,404 5,839-6,434 Source: National Vital Statistics System, National Center for Health Statistics, CDC Figure 5 ge-djusted Death Rates for Oklahoma Counties, 1998 Kay Cimarron exas Beaver Harper Woods lfalfa Grant Osage >10% above state rate 0-10% above state rate 0-10% below state rate >10% below state rate Woodward Garfield Noble Major Pawnee Ellis Payne Dewey Logan Blaine Kingfisher Creek Nowata Craig Ottawa Rogers Delaware Mayes ulsa Wagoner Cherokee dair Roger Mills Lincoln Custer Muskogee Canadian Oklahoma Okfuskee Sequoyah McIntosh Cleveland Beckham Washita Haskell Caddo Grady Hughes Greer Kiowa McClain Pittsburgh Latimer LeFlore Harmon Pontotoc Comanche Garvin Jackson Coal Stephens Murray toka Pushmataha illman Johnston Cotton Carter McCurtain Jefferson Marshall Choctaw Love Bryan Pottowatomie Seminole Washington Okmulgee W O R K I N G O G E H E R O I M P R O V E

9 Underlying Causes We know what diseases and injuries are making Oklahoma unhealthy. But, why do we have these problems at rates higher than the rest of the nation? What are the underlying causes? he behavioral risk factors already discussed are a partial explanation, especially nicotine addiction. But there are others. Economic Reasons Numerous studies show a strong association between income and poor health outcomes. Oklahoma ranks 45th out of 50 states for personal income levels (U.S. Bureau of Economic nalysis, 1999). Moreover, Oklahoma s rate of increase for personal income has not kept pace with the national rate of increase as can be seen in Figure 6. Such poor income levels have a particularly significant impact on all of us, but especially on our children. Over 32 percent (more than 76,000) of Oklahoma s children under age 5 live in poverty (U.S. Census Bureau, February 1999). Figure 6 Personal Income Levels, US & Oklahoma, $30,000 US Oklahoma $25,000 $20,000 7 $15, Even with risky behaviors such as smoking, income levels play a significant role. s Figure 7 shows, percentages of Oklahomans who smoke increase as income levels decrease (Oklahoma BRFSS, 1998). Nicotine addiction eventually results H E S E O F H E S E S H E L H

10 in health problems, and those with lower incomes are less likely to be able to afford adequate health care. lmost 50 percent of Native mericans in Oklahoma suffer from nicotine addiction. Socioeconomic factors play a role here as well. Figure 7 Percent of Current Smokers by Income Level, Oklahoma $75k $50k-75k $25k-50k $15k-25k <$15k 0% 10% 15% 20% 25% 30% 35% For many, the 1990s represented a time of prosperity. Income levels increased rapidly among various groups. However, this was not the case for everyone. here has been a disturbing trend in an increase in the gap between the haves and the have-nots. Figure 8, based on national data from the U.S. Census Bureau, shows the widening gap between those with the highest and lowest incomes. Such disparities in income only augment the disparities in health outcomes that we see between the wealthy and the poor. Lack of ccess to Health Care nother underlying cause of Oklahoma s poor health status indicators is lack of adequate access to health care. Health insurance coverage, in particular, continues to be a problem. ccording to CDC s BRFSS data, 22.5 percent of Oklahomans W O R K I N G O G E H E R O I M P R O V E

11 between the ages of 18 and 64 did not have health insurance coverage in his represents more than 532,000 people. When people do not have health insurance, they are more likely not to seek routine health care, especially preventive measures such as check-ups and screenings. Preventive measures and screenings are especially important because early detection for possible problems such as cervical cancer, breast cancer or heart disease can make all the difference in a successful treatment outcome. In addition, lack of access to routine health care often results in the use of emergency rooms for treating non-emergency conditions an expensive option that drives up the cost of health care for everyone. Figure 8 Comparison of US Highest and Lowest Incomes, $100,000 $80,000 $60,000 $40,000 $20,000 $ Inadequate Community Health Resources Between 1990 and 1998, 24 of Oklahoma s 77 counties experienced a decrease in population (U.S. Census Bureau). s we see our population distribution shift from rural to urban, those remaining in rural counties are at risk for hospital closings and lack of medical care. his is a growing concern for Oklahoma. H E S E O F H E S E S H E L H

12 Solutions So, we know in some measure what is making Oklahoma unhealthy. Now, it is time for us to consider and implement solutions. his important work for the future of our state s health cannot be done in a vacuum. Neither the State Board of Health or the Oklahoma State Department of Health can do this work alone. It requires a collaborative, cooperative effort between concerned citizens, physicians, business leaders, public health workers, faith leaders and others in our state who want to make difference. t the very least, our children deserve a healthier future. heir future is tied to what we do now! Clinical Prevention n ounce of prevention is worth a pound of cure rings as true today as it did over 200 years ago when first written by Benjamin Franklin. Reduction of risk factors through lifestyle behavior changes and appropriate preventive measures is a very basic, yet extremely important change that is needed in our health care delivery system. here will always be a need to treat those who are ill through primary care and medical specialties. However, physicians can have a powerful impact on preventing disease by stressing prevention in their clinical practices. For example, many deaths from heart attacks, Oklahoma s leading cause of death, can be prevented by the appropriate, early administration of beta blockers for those at risk. Some clinical preventive practice efforts are already underway. he Oklahoma Foundation for Medical Quality is working with physicians and hospitals to improve the health of Medicare recipients by focusing on preventive measures for some of Oklahoma s leading causes of death, including heart attack and stroke. he Oklahoma State Medical ssociation s Campaign for a Healthier Oklahoma will emphasize clinical prevention practices, healthy message reminders for patients, and physician involvement in community prevention initiatives. W O R K I N G O G E H E R O I M P R O V E

13 We call on physicians to participate in such efforts and join us as partners in promoting preventive practices for Oklahoma. Individuals must do their part as well. It is an individual s responsibility to adopt behaviors conducive to health, such as not smoking, exercising regularly, and maintaining a healthy diet. aking responsibility for your health and working together with your physician on prevention can lead to a lifetime of high quality, healthful living. Statewide Initiatives We have identified tobacco use as the one behavioral risk factor that has the most negative impact on the health of Oklahomans. herefore, we recommend the immediate implementation of a statewide, comprehensive, evidence-based tobacco prevention and reduction program that includes surveillance systems, community-based programs, media campaigns, school-based education, cessation products and services, and program evaluation. Funding for this statewide tobacco use prevention initiative should come from tobacco settlement funds. he Oklahoma State Department of Health should coordinate the tobacco use prevention initiative, serve as a technical resource, and assist in data collection and evaluation. However, the implementation of interventions should be done at the community level by community partners. Unwanted and unintended pregnancies must decrease. he negative health and 11 socioeconomic outcomes associated with unwanted and unintended pregnancies including high rates of low-weight births, physical violence, and poverty are unacceptable. herefore, we recommend the immediate implementation of a statewide initiative to reduce unwanted and unintended pregnancies, especially among teens, through appropriate, comprehensive educational and preventive H E S E O F H E S E S H E L H

14 measures. Funding for such a program should be similar to the successful Children First program, with the same commitment to quality, follow-up, and evaluation. Partnership pproach to Public Health Decision-Making Our final recommendation is to formally endorse a process in Oklahoma that will result in a fundamental change in how we approach public health and prevention. In the introduction of this report, we said that coordinated prevention activities must be our top priority. If we do not involve the people in the process of change who will be responsible for implementing the change, change will not occur. (o assist with this process, county-specific data is available upon request by calling 405/ ) process that has been developed to implement such change through a coordinated effort is the Oklahoma urning Point Initiative. Based on the notion of shared responsibility for health, urning Point seeks to impact health at the community-level, through the active participation of physicians, public health professionals, business leaders, state government, our faith leaders and other community partners in decisions about public health and prevention activities. he foundation for restructuring public health in Oklahoma through communitybased decision making has been established in the Oklahoma Public Health Innovation Plan prepared by the Oklahoma urning Point dvisory Committee and the Oklahoma community urning Point partners. his plan, with its recommendations, should be fully implemented with the emphasis of assisting other communities in developing urning Point partnerships across Oklahoma. W O R K I N G O G E H E R O I M P R O V E

15 Conclusion We can wait no longer. We are at an urgent point in time. If we do not make the right decisions about our state s public health and health care systems, we may witness a spiraling trend toward worsening health status. It is critical that we enter the new millennium with a renewed spirit to create an improved state of health. he work we do now will have a lasting impact on our people. Collaboration and cooperation are the keys. ogether, as partners, we must think differently about our preventive approaches, coordinate our efforts, and challenge ourselves to take risks that will ultimately improve the health of Oklahoma s future generations. 13 H E S E O F H E S E S H E L H

16 Board of Health Jay. Gregory, MD, President John B. Carmichael, DDS, Vice President Ron L. Graves, DDS, Secretary-reasurer Gordon H. Deckert, MD Glen E. Diacon, Jr., MD Haskell L. Evans, Jr., RPh Dan H. Fieker, DO Ron Osterhout R. Brent Smith, MD W O R K I N G O G E H E R O I M P R O V E

17 his year s design of the State of the State s Health report has been changed to reflect our emphasis on solutions. We believe this is an important change in how we report the state s health and look toward the future to improve our health status. Solutions: Working ogether to Improve the State of the State s Health 2000 Report of the Oklahoma State Board of Health 15 Graphic Design Shauna Schroder Faltyn his publication, printed by the University of Oklahoma Printing Services, is issued by the Oklahoma State Department of Health as authorized by Jerry Nida, MD, Commissioner of Health. 7,500 copies were printed in December 1999, at a cost of $9,300. Copies have been deposited with the Publications Clearinghouse of the Oklahoma Department of Libraries. H E S E O F H E S E S H E L H