The Onondaga County Community Health Assessment and Improvement Plan 2014 2017

The Onondaga County Community Health Assessment and Improvement Plan 2014 2017 Cynthia B. Morrow, MD, MPH, Commissioner of Health Rebecca Shultz, MPH, Director, Bureau of Surveillance and Statistics

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Table of Contents 1) Executive Summary... 7 2) Community Health Assessment... 11 a) Overview of Onondaga County... 11 b) Part A: Population Characteristics... 13 c) Part B: Socioeconomic Characteristics... 18 d) Part C: Health Status and Distribution of Health Issues... 24 i) Improving Health Status and Reducing Health Disparities... 24 ii) Prevention Agenda Area: Preventing Chronic Disease... 29 iii) Prevention Agenda Area: Promoting a Healthy and Safe Environment... 35 iv) Prevention Agenda Area: Promoting Healthy Women, Infants and Children... 40 v) Prevention Agenda Area: Promoting Mental Health and Preventing Substance Abuse... 45 vi) Prevention Agenda Area: Preventing HIV/STDs, Vaccine Preventable Diseases and Health Care Associated Infections... 49 e) Part D: Determinants of Health and Main Health Challenges... 51 f) Part E: The Onondaga County Health Department and Other Assets and Resources... 55 g) Part F: Community Engagement Process and the Methodology of the Community Health Assessment... 59 3) Community Health Improvement Plan... 62 a) Background... 62 b) Drug Related Discharges in Newborns in Onondaga County... 65 c) Impacting Chronic Disease in Onondaga County... 71 i) The Near Westside Neighborhood... 71 ii) Healthy Syracuse... 75 d) Process Improvement: Lessons Learned... 77 e) Sustainability of Community Engagement... 78 1

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Appendices To access the appendices referenced in this document, please visit our website at www.ongov.net/health 1. Data Tables a) Preventing Chronic Disease b) Promoting a Healthy and Safe Environment c) Promoting Healthy Women, Infants and Children d) Birth Outcomes by Zip Code e) Promoting Mental Health and Preventing Substance Abuse f) Preventing HIV/STDs, Vaccine Preventable Disease and Health Care Associated Infections g) Data Table Technical Notes 2. Expanded BRFSS Preliminary Report, 2013 2014 3. Onondaga County Health Department Organizational Chart 4. Onondaga County Assets and Resources 5. Report on Findings of Community Forums 6. Schedule of CHA meetings 7. State of the County s Health 8. The Community Health Assessment Process a) Community Health Needs Assessment and Community Engagement b) Lerner Center and MPH Program Community Engagement Forums 9. Drug related Discharges in Newborns in Onondaga County 10. Onondaga County Health Department s Journey to the Summit 11. Prevention Quality Indicators 12. The Tree of Health Acknowledgement The Onondaga County Health Department gratefully acknowledges the contributions of Thomas H. Dennison, PhD and his Masters students from Syracuse University and Upstate Medical University for all of their hard work in the research and preparation of this document. 2

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 List of Figures Figure 1: Location of Onondaga County within New York State... 11 Figure 2: Map of Onondaga County... 11 Figure 3: Urban population by census tract, Onondaga County, 2010... 12 Figure 4: Population distribution by age group, Syracuse, Onondaga County and New York State, 2009 2011... 13 Figure 5: Projected age distribution for Onondaga County, 2030... 14 Figure 6: Population by race, Onondaga County, 2009 2011... 15 Figure 7: Population by race, Syracuse, 2009 2011... 15 Figure 8: Population by Hispanic ethnicity, Onondaga County, 2009 2011... 16 Figure 9: Population by Hispanic ethnicity, Syracuse, 2009 2011... 16 Figure 10: Unemployment by race, Syracuse, Onondaga County and New York State, 2009 2011... 19 Figure 11: Percent of residents by income, Onondaga County and Syracuse, 2009 2011... 20 Figure 12: Percent of families living below the federal poverty level, Onondaga County and Syracuse, 2009 2011... 21 Figure 13: Demographic disparities between Onondaga County and the City of Syracuse... 23 Figure 14: Racial and ethnic disparities in premature deaths, 2008 2010... 25 Figure 15: Percent of deaths by age category, race and sex, Onondaga County, 2008 2010... 26 Figure 16: Survivorship by sex and age for selected races, Onondaga County, 2008 2010... 26 Figure 17: Racial and ethnic disparities in preventable hospitalizations, 2008 2010... 27 Figure 18: Age adjusted mortality rate for diseases of the heart, 2009 2011... 29 Figure 19: Age adjusted mortality rate for coronary heart disease, 2009 2011... 30 Figure 20: Age adjusted incidence and mortality rates for all types of cancer, Onondaga County, 1994 2008... 31 Figure 21: Incidence of breast, lung and prostate cancers in Onondaga County, New York State and the U.S., 2007 2009... 31 3

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Figure 22: Mortality from breast, lung and prostate cancers in Onondaga County, New York State and the U.S., 2007 2009... 32 Figure 23: Obesity rates in Onondaga County, New York State and the U.S.... 33 Figure 24: Diabetes mortality in Onondaga County, New York State and the U.S., 2009 2011... 33 Figure 25: Asthma hospitalizations in Onondaga County and New York State, 2009 2011... 36 Figure 26: High school graduation rates and the percent of students receiving free or reduced lunch by district, 2008 2009... 37 Figure 27: Access to grocery stores by census tract, 2010... 38 Figure 28: Age adjusted homicide rate, Onondaga County and comparison geographies, 2008 2010... 39 Figure 29: Infant mortality by race, three year averages, Syracuse, NY, 1985 2011... 40 Figure 30: Preterm births and low birth weight births by race and ethnicity, 2009 2011... 41 Figure 31: Racial and ethnic disparities in adolescent pregnancy, Onondaga County, 2009 2011... 42 Figure 32: Racial and ethnic disparities in unintended pregnancy, Onondaga County, 2009 2011... 42 Figure 33: Births to adolescent females, Onondaga County and New York State, 2009 2011... 43 Figure 34: Breastfeeding in Onondaga County, 2009 2011... 44 Figure 35: Age adjusted suicide rate, Onondaga County, New York State and the U.S., 2009 2011... 46 Figure 36: Births to women with self reported illegal drug use, Onondaga County and Syracuse, 2007 2009 and 2010 2012... 47 Figure 37: NICU admissions, Onondaga County, January May 2012... 48 Figure 38: Gonorrhea incidence by year, Onondaga County, 2010 2012... 49 Figure 39: Gonorrhea incidence by age and sex, Onondaga County, 2012... 50 Figure 40: Distribution of determinants of health... 51 Figure 41: Broadening the focus of determinants of health... 54 Figure 42: Image 1 from community forum, Onondaga County, Fall 2011... 59 Figure 43: Image 2 from community forum, Onondaga County, Fall 2011... 59 4

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 List of Tables Table 1: Highest level of education obtained among adults age 25 years and older, Syracuse, Onondaga County and New York State, 2009 2011... 18 Table 2: Free and reduced price lunch by school district, 2011 2012... 21 Table 3: Indicators for the New York State Prevention Agenda: Improve Health Status and Reduce Health Disparities... 24 Table 4: Environmental indicators... 35 Table 5: Schooling indicators... 36 Table 6: Infant mortality in Onondaga County and Syracuse, 2010 2012... 41 Table 7: Adolescent births per 1,000 females by select zip codes, 2009 2011... 43 Table 8: Self inflicted injury hospitalizations per 10,000 population, Onondaga County and New York State, 2009 2011... 45 5

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The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Executive Summary The following document, The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017, presents demographic and health indicator data for residents of Onondaga County and outlines the community s plan to address two priority health issues. The New York State Department of Health (NYSDOH) requires that local health departments (LHDs) complete a community health assessment (CHA) and community health improvement plan (CHIP) every 3 5 years. Together, the CHA and the CHIP are designed to ensure that LHD priorities accurately reflect the needs of the community and to ensure that there is accountability in addressing those needs. Recognizing that improving the public s health is a shared responsibility of many partners, the NYSDOH requires the CHA/CHIP to be developed through a collaborative process between LHDs, local hospitals, and other community partners. In Onondaga County, this process began in the fall of 2011 with graduate students in the Central New York Master of Public Health (CNYMPH) program convening and facilitating five community forums. The forums were the platform to engage a broad array of individuals and organizations to help identify important health issues in the community. Key findings from the community forums: Social factors, particularly education and the economic environment, were identified by participants as having a significant impact on the overall health status of the community. A dominant theme was how lack of access to health care, especially primary care and mental health care, is a major contributing factor to poor health outcomes. Physical activity and nutrition, mental health/substance abuse, and maternal and child health were the three most commonly identified areas of concern with respect to health indicators. A formal data collection and analysis phase followed the community forums. Regular meetings were held between Onondaga County Health Department (OCHD) leadership and representatives from each area hospital to review the data and identify areas for further collaboration. Data were collected and analyzed in alignment with the five priority areas addressed in the NYSDOH Prevention Agenda 2013 2017: Preventing Chronic Disease; Promoting a Healthy and Safe Environment; Promoting Healthy Women, Infants and Children; Promoting Mental Health and Preventing Substance Abuse; and Preventing HIV, Sexually Transmitted Diseases, Vaccine Preventable Diseases and Healthcare Associated Infections. Improving Health Status and Reducing Health Disparities is an overarching priority area that is present throughout the other five. The below highlights aspects of each priority area where Onondaga County fares either markedly better or markedly worse than the rest of NYS. Key findings on the health status of Onondaga County residents: Improving Health Status and Reducing Health Disparities Overall, Onondaga County fares better than New York State (NYS) for many baseline Prevention Agenda indicators. Despite this, the County faces considerable challenges with respect to achieving health equity. In Onondaga County: Fewer residents die before age 65 (22.4%) compared to NYS (24.2%). But more residents report 14 or more days of poor physical health in the past month (15.4%) compared to NYS (12.1%). 7

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Nearly 93% of residents report having health care coverage. For each white non Hispanic death, there are 2.5 black non Hispanic and 2.5 Hispanic deaths. Black males are much more likely to die before age 65 (59.1%) than white males (25.1%). Preventing Chronic Disease Onondaga County fares better than NYS on indicators of heart disease but worse on indicators of cancer morbidity and mortality despite high screening rates. Indicators for diabetes and obesity remain of particular concern, as rates continue to increase. In Onondaga County: The heart disease mortality rate is 150.9 per 100,000 compared to 198.6 per 100,000 for NYS. Incidence rates for both lung and prostate cancers are significantly higher in Onondaga County compared to NYS and the U.S. Among adults age 50 75, 86.0% have been screened for colorectal cancer compared to 65.7% in NYS. Obesity is increasing with 20.0% of adults and 16.1% of children considered obese. A greater percentage of residents have been told by their health care provider that they have diabetes (13.9%) compared to NYS (9.4%). Promoting a Healthy and Safe Environment For many indicators in this priority area, Onondaga County is not significantly different from NYS. There are areas that warrant further investigation, such as increased mortality due to unintentional injury. Of particular concern is the racial disparity seen in homicide rates. Numerous community partners have already committed to collaborating on this issue. In Onondaga County: Among adults, 8.7% report having physician diagnosed asthma compared to 10.0% for NYS. High school graduation rates range from 95% to 52% depending on the school district. Low access to a grocery store impacts 5.5% of low income residents and 6.3% of children. The unintentional injury mortality rate is 31.1 per 100,000 population compared to 22.7 per 100,000 for NYS. The homicide rate for black residents is 15 times the rate for white residents. Promoting Healthy Women, Infants and Children Onondaga County continues to witness challenges in this priority area, with unacceptable racial and ethnic disparities in infant mortality, low birth weight, pre term deliveries, and adolescent pregnancies. While concerning, most of the indicators are trending down, indicating that overall outcomes are improving. One area that represents a serious threat to the health of women in Onondaga County and their infants is drug dependence, which is explored thoroughly in the next section. 8 In Onondaga County: The infant mortality rate (IMR) is 5.5 per 1,000 live births. A substantial racial disparity exists between black and white residents, with IMRs of 4.3 per 1,000 and 12.4 per 1,000, respectively.

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 There are 26.4 births per 1,000 females age 15 19 compared to 22.7 per 1,000 for NYS. A disproportionate number of teen births are in Syracuse city zip codes where rates range from 42.3 per 1,000 to 107.7 per 1,000. Mothers participating in WIC are far less likely to breastfeed for at least 6 months (17.9%) compared to NYS (38.3%). Promoting Mental Health and Preventing Substance Abuse Onondaga County compares unfavorably to NYS in several key indicators in this priority area, including selfreported mental health status, suicide, self inflicted injury, and binge drinking. An alarming increase in heroinrelated overdoses has been documented in the last four years. Most shocking is the very high rate of drugrelated newborn hospital discharges in Onondaga County. While this is not a priority indicator in the NYS Prevention Agenda, it is a priority for Onondaga County, and will be addressed in the CHIP. In Onondaga County: Among adults, 17.4% reported 14 or more days of poor mental health in the past month, compared to 10.3% for NYS. Self inflicted injury hospitalizations among adults and among teens age 15 19 are significantly higher than NYS, and appear to be trending upward. Binge drinking in the past month was reported by 21.9% of adults, compared to 14.8% for NYS. The rate of overdose deaths associated with heroin use has increased substantially over the past 4 years. The newborn drug related discharge rate is more than 3 times higher than that for NYS (248.3 per 10,000 births compared to 72.6 per 10,000 births, respectively). Preventing HIV/STDs, Vaccine Preventable Diseases, and Health Care Associated Infections Overall, Onondaga County fares well compared to NYS in this priority area, particularly with respect to immunization rates and newly diagnosed cases of HIV. Unfortunately, Onondaga County has seen a dramatic increase in gonorrhea cases over the past year. Incidence rates for chlamydia and syphilis also appear to be trending upward. In Onondaga County: The HIV case rate is 8.4 per 100,000 compared to 20.0 per 100,000 for NYS. In the past year, 54.3% of adults received their flu shot or spray compared to 48.2% for NYS. The incidence rate for gonorrhea has more than doubled in 2012 compared to 2011 (188.4 per 100,000 and 86.5 per 100,000, respectively). The increase in gonorrhea incidence disproportionately impacts females age 15 24. In examining the qualitative and quantitative data in combination with community input, OCHD and hospital leadership chose two priority areas to address: Preventing Chronic Disease, with a focus on nutrition and physical activity, and Promoting Mental Health and Preventing Substance Abuse/Promoting Healthy Women, Infants and Children, with a focus on neonatal abstinence syndrome. Opportunities to address health 9

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. disparities exist within each of the chosen priority areas, and the specific areas of focus have found considerable support and momentum within the community. The CHIP specifies the activities that will be undertaken by community partners, the OCHD, and local hospitals to measurably improve health outcomes in these areas. Throughout the CHA/CHIP process it became increasingly apparent that a very strong, diverse network of committed community partners exists in Onondaga County. While there are gaps in the assets and resources available to fully address all of the public health issues noted in the CHA, the level of collaboration and engagement experienced during the development of the CHA/CHIP reinforced the vision of the OCHD: A community of partners working together for the physical, social, and emotional well being of all. 10

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Onondaga County* Onondaga County is located in Central New York State (Figure 1). It covers 780 square miles and is bordered by Oswego County to the north, Cayuga County to the west, Cortland County to the south, and Madison County to the east. Figure 1. Location of Onondaga County within New York State Source: http://en.wikipedia.org/wiki/file:map_of_new_york_highlighting_onondaga_county.svg The population of Onondaga County is 466,852 (2012) making it the sixth most populous county in upstate New York (i.e., New York excluding New York City). Onondaga County consists primarily of forests and agricultural lands, resulting in a population density of 600 persons/mi 2. The County seat is the City of Syracuse, located near the center of the county as seen in Figure 2. In addition to Syracuse, 19 towns, 15 villages and the Onondaga Nation territory lie within the County s borders. Of note, Onondaga County also contains the intersection of Interstates 90 and 81 which are major east west and north south thoroughfares. Figure 2. Map of Onondaga County Source: New York State. http://www.nysegov.com/map NY.cfm *All data in this section are from the U.S. Census Bureau unless otherwise noted. 11

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Syracuse is the largest city in the Central New York (CNY) region with a population of 145,135, accounting for almost one third of the total county population. Syracuse is the fourth largest upstate NY city, after Buffalo, Rochester, and Yonkers. Other heavily populated towns in Onondaga County include Clay, Salina, and Cicero in the northwest sector and Dewitt and Manlius in the southeast. Figure 3 shows the urban population of Onondaga County by census tract for 2010. Urban population is defined as the percentage of residents of a territory who live in areas that encompass at least 2,500 people, at least 1,500 of which reside outside institutional group quarters. Figure 3. Urban population by census tract, Onondaga County, 2010 Urban Population, Percent by Tract, 2010 Census 100% Urban Population 90.1 99.9% 50.1 90.0% Under 50.1% No Urban Population Source: Community Commons Map Room at http://www.communitycommons.org/maps data/ 12

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Part A: Population Characteristics The demographic characteristics of a population are associated with a variety of health outcomes including health associated behaviors, as well as with health care access and utilization. Significant differences in the demographics between residents of Syracuse and the rest of Onondaga County contribute to geographic disparities in health. Given the extent of these differences, data are presented separately for Syracuse and Onondaga County, where available. Other disparities are also addressed in this section. Age and Gender Age distribution can have a major impact on the health outcomes and the health care needs of a community. The median age in Onondaga County is 38.7 years; greater than the median age of 29.2 years in Syracuse. Although Onondaga County s population distribution is relatively comparable to that of New York State (Figure 4), Syracuse s population skews younger than either, with both a higher proportion of residents under age 5 years and a lower proportion over age 65. Figure 4. Population distribution by age group, Syracuse, Onondaga County and New York State, 2009 2011 Percent 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% Under 5 years 5 to 9 years 10 to 14 years 15 to 19 years 20 to 24 years 25 to 29 years 30 to 34 years 35 to 39 years 40 to 44 years 45 to 49 years 50 to 54 years 55 to 59 years 60 to 64 years 65 to 69 years 70 to 74 years 75 to 79 years 80 to 84 years 85 years and older Syracuse Onondaga County New York State Source: U.S. Census Bureau, American Community Survey, 2009 2011 13

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. There are over 27,000 children under age 5 in Onondaga County, representing 5.9% of the population. Outside of Syracuse, there are relatively large numbers of preschoolers living in the towns of Clay, Cicero, Salina, Manlius, and Dewitt. With respect to older populations, over 65,000 county residents are age 65 years and older (14.0%). Outside of Syracuse, substantial populations of senior citizens reside in the towns of Clay, Salina, Manlius, Dewitt, and Camillus. Projections from the Cornell Program on Applied Demographics indicate that by 2030, nearly 20% of Onondaga County s population will be age 65 years or older (Figure 5). Elderly populations typically encounter unique health issues that the County must be prepared to address over the next 15 years. Figure 5. Projected age distribution for Onondaga County, 2030 Source: Cornell Program on Applied Demographics, 2011: http://pad.human.cornell.edu/counties/projections.cfm With respect to gender distribution, women comprise 51.8% of the population of Onondaga County and 52.3% of the population of Syracuse. Women of childbearing age (generally 15 44 years) have specific health needs and health risks. There are nearly 95,000 women in this category in Onondaga County, with roughly 37,000 residing in Syracuse. 14

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Race and Ethnicity Among Onondaga County residents, 97.6% identify as being one race. Of these, 81.6% self identify as white and 10.9% as black (Figure 6). The majority of the County s black residents reside in Syracuse (Figure 7), particularly on the near south and near west sides of the city. Between the 2000 and 2010 Census, the black population in Syracuse increased by almost 16%. Asians and American Indian/Alaska Natives comprise additional racial groups represented in comparatively large numbers. Approximately three percent of Onondaga s total population self identifies as Asian and 0.7% self identifies as Native American. Figure 6. Population by race, Onondaga County, 2009 2011 10.9% 0.7% 3.2%1.1% 2.4% White Black or African American American Indian and Alaska Native Asian Some other race 81.6% Two or more races Source: U.S. Census Bureau, American Community Survey, 2009 2011 Figure 7. Population by race, Syracuse, 2009 2011 5.4% 0.9% 2.8% 4.1% White Black or African American American Indian and Alaska Native 29.3% Asian Some other race 57.5% Two or more races Source: U.S. Census Bureau, American Community Survey, 2009 2011 15

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Hispanic ethnicity is reported by over 19,000 County residents of all races (4.1%, Figure 8). This represents a 70% increase in Hispanic ethnicity from the 2000 U.S. Census. Currently, nearly two thirds of local Hispanics reside in Syracuse, particularly in neighborhoods on the near west side of the city (Figure 9). The towns of Clay, Geddes, and Salina also have notable numbers of Hispanic residents. Figure 8. Population by Hispanic ethnicity, Onondaga County, 2009 2011 Source: U.S. Census Bureau, American Community Survey, 2009 2011 Figure 9. Population by Hispanic ethnicity, Syracuse, 2009 2011 Source: U.S. Census Bureau, American Community Survey, 2009 2011 16

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 In Onondaga County, 7.3% of residents are foreign born. Among foreign born Onondaga County residents, the greatest percentage was born in Asia, followed by Europe, Latin America, and Africa. The percent of foreignborn residents increases to 11.2% in Syracuse, where the largest percentage was also born in Asia, followed by Latin America, Europe, and Africa. A number of foreign born residents, particularly in Syracuse, are recently settled refugees. Since 2007, over 6,000 refugees, including 2,000 children, have resettled in the Syracuse area. While refugees have resettled from many countries in Southeast Asia, Africa and the Middle East, the primary countries of origin include Burma/Myanmar, Bhutan, Thailand, Nepal, Somalia, and Iraq. Job opportunities and the relatively low cost of living continue to make the Syracuse area popular for resettlement. According to the 2012 Onondaga County Citizens League report, an estimated 12,000 refugees and former refugees currently reside in Syracuse; many in neighborhoods on the north side of the city (http://onondagacitizensleague.org/). Newly arrived refugees have specific healthcare needs, as well as a unique set of barriers to accessing care, including language, education, and transportation. Ensuring access to care and improved health outcomes for this vulnerable population requires a coordinated response among many local service agencies. Spoken languages and linguistic isolation English language proficiency can impact everything from an individual s educational success to his/her ability to communicate with healthcare providers and to secure employment. In Onondaga County, English is the most commonly spoken language. The next most commonly spoken language is Spanish, which is the primary spoken language at home for 2.9% of Onondaga County residents and 6.3% of Syracuse residents ages 5 and older. Primary speakers of other Indo European languages (e.g., French, Polish, Ukrainian, Russian, Bosnian, Turkish, etc.) account for 4.1% of county residents and 4.5% of Syracuse residents. Primary speakers of Asian and Pacific Islander languages (e.g., Chinese, Burmese, Nepalese, Karen dialects, etc.) account for 2.0% of county residents and 3.7% of Syracuse residents. Primary speakers of other languages (e.g., Arabic; American Indian languages including Onondaga; African languages including Swahili and other Bantu languages; Somali, etc.) account for 0.9% of county residents and 2.0% of Syracuse residents. A household is considered linguistically isolated if all adults (age 14 and older) speak a language other than English and none speaks English very well. Individuals who speak a language other than English at home and do not speak English very well are also considered linguistically isolated. Compared to NYS and to the U.S., Onondaga County residents are less likely to be linguistically isolated, with only about 6.2% of households speaking a language other than English and only 3.7% speaking English less than very well. As with other comparable indicators, Syracuse residents are more likely to be linguistically challenged than County residents, with 9.7% of households speaking a language other than English and 6.8% speaking English less than very well. With respect to English language proficiency among children, 11.9% of the over 22,000 students in the Syracuse City School District are English language learners (ELLs). These students represent 80 countries, with 74 different languages spoken. Approximately half of ELLs are refugees. Most other ELLs are secondary refugees or migrants, immigrants, or individuals who were born in the U.S., but grew up in a home where a language other than English is spoken. 17

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Part B: Socioeconomic Characteristics Education Educational attainment is an important predictor of health outcomes. As seen in Table 1, among adults age 25 years and older in Onondaga County, 89.3% have a high school education or higher, and 32.6% have a bachelor s degree or higher. In Syracuse, these fall to 80.2% and 26.1% respectively. Table 1. Highest level of education obtained among adults age 25 years and older, Syracuse, Onondaga County and New York State, 2009 2011 City of Syracuse Onondaga County New York State Less than high school education 19.9% 10.7% 15.1% High school graduate or higher 80.2% 89.3% 84.8% Bachelor's degree or higher 26.1% 32.6% 32.6% Source: U.S. Census Bureau American Community Survey, 2009 2011 There are 18 public school districts in Onondaga County with an enrollment of approximately 70,000 students, including over 22,000 students in the Syracuse City School District (SCSD). Thirty four private or parochial schools in the county educate an additional 8,165 students. Disparities in education outcomes between Syracuse and the rest of the county are evident, as SCSD students consistently score significantly below the state average on standardized tests. The district is generally considered one of the lowest performing in New York State, as evidenced by the low pass rate on tests administered between grades 3 and 8 (pass rates ranged from 19% to 31% for all tests over the 6 grades). In addition, the high school dropout rate in Syracuse was 11% for the 2011 12 school year, significantly higher than the average rate of 1% seen in suburban schools. Within the SCSD, the average graduation rate is 52% compared with the average suburban district rate of 84.4%. The percent of graduates in Syracuse who will go on to some type of college is 77.2%, compared with 86.8% among suburban students (New York State Report Cards, 2011 2012). Unique to the Syracuse area is the Say Yes to Education program. Initiated in 2008, the mission of this program is to dramatically increase high school and college graduation rates for urban youth. To achieve this mission, the program seeks to unite a diverse group of academics, educators, government agencies, corporations, research institutions, and community partners to provide support to SCSD students. This support is demonstrated through offering extended academic programming, mentoring, tutoring, family outreach, health care, social work, psychological services, and/or legal assistance. One exceptional feature of the Say Yes program is the promise of free college tuition at participating colleges for those SCSD students who meet residency, graduation, and admission requirements. Since 2009, nearly 2,000 Say Yes students have enrolled in 2 and 4 year colleges. Other positive outcomes have been observed, including a 3.5% increase in Syracuse city home values since the program s inception. The impact of Say Yes to Education in Syracuse will continue to be evaluated in the years to come. (Source: Say Yes to Education, Syracuse.) 18

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 The Central New York region is home to a large number and variety of post secondary educational institutions. Over 32,000 students currently attend colleges within Onondaga County, including but not limited to Syracuse University, LeMoyne College, SUNY Upstate Medical University, SUNY College of Environmental Science and Forestry, and Onondaga Community College. Two local hospitals also have Colleges of Nursing. A number of other professional and licensing programs are offered in the county. Furthermore, an additional 35 institutions of higher learning are located within 100 miles of Onondaga County. Employment According to the American Community Survey (ACS) 2007 2011, the educational services, health care and social assistance sectors employ 29.3% of Onondaga County civilians ages 16 and older. This is followed by the retail trade (11.7%); the professional, scientific, and management and administrative and waste management sectors (9.5%); manufacturing (9.1%); and the arts, entertainment and recreation and accommodation and food services sectors (8.2%). According to the Onondaga County Office of Economic Development, the leading employer in the Onondaga County area is Upstate University Health System with 9,525 employees. Other major employers in the area include Syracuse University, St. Joseph s Hospital Health Center, Wegmans, Crouse Hospital, and Onondaga County government. Recent data from the New York State Department of Labor show job growth in the Syracuse Metropolitan Statistical Area (MSA) in the fields of education and health, trade, transportation and utilities, and leisure and hospitality. Recent job losses have occurred in the manufacturing, financial activities and information sectors. According to the U.S. Bureau of Labor Statistics, the unemployment rate in Onondaga County was 7.1% in April 2013, and has declined slowly from a high of 8.8% in January 2010. The current unemployment rate is nearly identical to the statewide unemployment rate of 7.3% in April 2013. Consequences of unemployment can include a decrease in health care related expenditures and a decrease in access to employer sponsored health insurance programs, which may lead to higher rates of uninsured persons. As seen in Figure 10, racial Figure 10. Unemployment by race, Syracuse, Onondaga County and New York State, 2009 2011 disparities in unemployment exist both within Onondaga County and Syracuse. In general, white residents have lower unemployment rates than other races. The highest unemployment rate is seen in those who identify as some other race. Source: American Community Survey, 2009 2011 19

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Income The median household income in Onondaga County is $52,520. As illustrated in Figure 11, there is a significant disparity in income between Onondaga County and Syracuse residents. Figure 11. Percent of residents by income, Onondaga County and Syracuse, 2009 2011 30.0 25.0 24.6 23.1 25.7 Onondaga County Syracuse 20.9 20.0 18.5 18.7 16.5 Percent 15.0 14.2 12.6 10.0 8.1 7.0 9.9 5.0 0.0 Less than $10,000 $10,000 to $24,999 $25,000 to $49,999 $50,000 to $74,999 $75,000 to $99,999 $100,000 or more Source: U.S. Census Bureau, American Community Survey, 2009 2011 Poverty Among all residents, 14.7% had income in the last 12 months that was below the federal poverty level. Especially striking is the poverty rate among children in Syracuse, where 49.0% of those under age 18 live in poverty, compared to 21.0% of children in Onondaga County. Poverty rates for families can be seen in Figure 12. Poverty rates are consistently higher in Syracuse than in Onondaga County, peaking at 56.0% among female headed households with related children under 18 years of age. 20

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Figure 12. Percent of families living below the federal poverty level, Onondaga County and Syracuse, 2009 2011 Source: U.S. Census Bureau, American Community Survey, 2009 2011 21

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Another indicator of poverty is the percent of students receiving free or reduced price lunch at school. As seen in Table 2, this varies by school district, with a far greater percentage of students in the SCSD receiving free or reduced price lunch compared to the surrounding suburban school districts. Table 2. Free and reduced price lunch by school district, 2011 2012 School District Minority students Free or Reduced Lunch Baldwinsville 8.9% 22.3% East Syracuse Minoa 10.6% 33.5% Fabius Pompey 4.5% 23.6% Fayetteville Manlius 14.2% 8.3% Jamesville Dewitt 21.0% 13.2% Jordan Elbridge 3.6% 40.2% Lafayette 33.1% 35.3% Liverpool 17.7% 28.8% Lyncourt 17.2% 51.4% Marcellus 3.0% 12.9% North Syracuse 11.8% 28.3% Onondaga 16.4% 34.4% Skaneateles 3.7% 8.6% Solvay Union Free 15.9% 46.5% Syracuse City 73.9% 79.8% Tully 3.6% 37.1% West Genesee 9.0% 18.3% Westhill 8.1% 6.6% Data Source: NYS Report Cards, 2011 2012. In addition to children and families, seniors living in poverty warrant special attention. In Onondaga County, 7.6% of residents ages 65 years and older live in poverty, as do 17.4% of seniors in Syracuse. The poverty burden in an area can also be assessed through utilization of public benefits. In Onondaga County, nearly 9,000 (5.4%) households receive an average of $8,715 in Supplemental Security Income each year. Of these, nearly 5,700 are in Syracuse, representing 10.2% of city households. In addition, almost 5,600 county households receive cash public assistance income, 4,100 of which are in Syracuse. Almost 23,000 (12.4%) households receive Supplemental Nutrition Assistance Program (SNAP) benefits in Onondaga County, of which nearly 15,000 (26.9%) are in Syracuse. The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in Onondaga County served an average of 10,077 participants per month in 2012 (Onondaga County Health Department Annual Report). 22

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Health Insurance Another important factor relating to health outcomes and access to care is the presence of health insurance. In Onondaga County, 9% of residents do not have any health insurance. This increases to 13% in Syracuse. Housing Onondaga County has been largely insulated from the unstable housing market that has plagued much of the rest of the nation over the last several years. Recent data from the U.S. Bureau of Labor Statistics accessed through National Public Radio indicate that the current foreclosure rate in Onondaga County is just 1 in 12,647 homes. The ages of housing units in Onondaga County are similar to NYS averages. Compared to NYS, housing units are more likely to be owner occupied (65%) in Onondaga County but less likely to be owner occupied in Syracuse (40%) (ACS 2007 2011). The median home value in Onondaga County in 2010 was $134,700, compared to $88,400 in Syracuse. Disparities Overall, Syracuse has a younger and more racially and ethnically diverse population when compared to the rest of Onondaga County. In addition, there is higher poverty and lower educational attainment in Syracuse than in the surrounding suburban and rural areas. These factors are important predictors of health outcomes and should be considered when evaluating populations at risk and allocating resources for public health activities. Some of these disparities are highlighted in Figure 13. Figure 13. Demographic disparities between Onondaga County and the City of Syracuse Source: U.S. Census Bureau, American Community Survey, 2009 2011 23

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Part C: Health Status and Distribution of Health Issues in Onondaga County All data are from sources accessed through the New York State Department of Health (NYSDOH) Community Health Assessment Clearinghouse unless otherwise indicated. Improving Health Status and Reducing Health Disparities: According to Healthy People 2020, a disparity exists if a health outcome is seen in a greater or lesser extent between populations (Disparities 2010, retrieved from healthypeople.gov). As part of an overall Community Health Assessment, health disparities must be addressed. Four primary indicators are intended to capture health outcome and access categories that are representative of overall health status and disparities in Onondaga County. Table 3. Indicators for the New York State Prevention Agenda: Improve Health Status and Reduce Health Disparities Indicator Percentage of premature deaths (before age 65 years) Ratio of black non Hispanic to white non Hispanic Ratio of Hispanic to white non Hispanic Age adjusted preventable hospitalization rate (per 10,000) (SPARCS) Ratio of black non Hispanic to white non Hispanic Ratio of Hispanic to white non Hispanic Percentage of adults with health care coverage (Age 18 64 years) (Expanded BRFSS Preliminary Report, 2013 2014) Percentage of adults who have a regular health care provider (Expanded BRFSS Preliminary Report, 2013 2014) Onondaga County (2008 2010) NYS (2010) NYS Prevention Agenda Objective 22.40 24.20 21.80 2.53 2.08 1.87 2.53 2.07 1.86 131.20 148.10 133.30 2.50 2.06 1.85 1.20 1.53 1.38 92.8 83.3 100.00 90.0 84.9 90.80 Source: New York State Department of Health Prevention Agenda 2013 2017. Office of Vital Statistics 24

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Premature Deaths The percentage of premature deaths was calculated by aggregating the number of deaths occuring before age 65 per 100 total deaths in the specified time period (2008 2010). Overall, 22.4% of Onondaga County residents die prematurely, compared to 24.2% for New York State. Black non Hispanics and Hispanics experience a much higher rate of premature deaths compared to white non Hispanics: for every one white non Hispanic premature death there are 2.53 black non Hispanic deaths and 2.53 Hispanic deaths (Figure 14). Figure 14. Racial and ethnic disparities in premature deaths, 2008 2010 White non Hispanics Black non Hispanics and Hispanics For every one white non Hispanic premature death, there are 2.53 for both black non Hispanic deaths and Hispanic deaths in Onondaga County Source: http://www.health.ny.gov/prevention/prevention_agenda/2013 2017/indicators/2013/onondaga.htm Local life table analyses provide a deeper look into the disparities surrounding mortality in Onondaga County. Figure 15 shows the percent of deaths in each age catgory by race and sex for 2008 2010. In Onondaga County, 59.1% of black males will die before age 65 years, compared to 25.1% for white males. Overall, there is a substantial disparity in mortality across all age groups between black and white residents of Onondaga County. Another way to assess disparities in premature death is by examining survivorship. Survivorship curves for race and sex are shown in Figure 16. This again illustrates the disparity in survival between white and black Onondaga County residents. 25

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Figure 15. Percent of deaths by age category, race, and sex; Onondaga County, 2008 2010 Source for Figures 15 and 16: Onondaga County Health Department, Bureau of Statistics and Surveillance Figure 16. Survivorship by sex and age for selected races, Onondaga County, 2008 2010 26

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Preventable Hospitalizations The number of preventable hospitalizations is measured by the Prevention Quality Indicators (PQIs), a set of measures developed by the Agency for Healthcare Research and Quality (AHRQ) used to assess the quality of outpatient care for "ambulatory care sensitive conditions" (ACSCs). The term preventable hospitalization refers to the combination of the 12 PQIs that pertain to adults: short term complication of diabetes, long term complication of diabetes, uncontrolled diabetes, and lower extremity amputation among patients with diabetes, hypertension, congestive heart failure, angina, chronic obstructive pulmonary disease, asthma, dehydration, bacterial pneumonia, and urinary tract infection. In 2010, the baseline rate of age adjusted preventable hospitalizations in New York State was 148.1 per 10,000 compared to Onondaga County s rate of 131.2 per 10,000. Onondaga County has already met the New York State Prevention Agenda goal of 133.3 overall age adjusted preventable hospitalizations per 10,000 for ages 18 and older. As with premature deaths, racial disparities in preventable hospitalization rates are apparent. This is most pronounced in the ratio of preventable hospitalization rates for white non Hispanics to black non Hispanics: for every one white non Hispanic preventable hospitalization, there are 2.5 preventable hospitalizations for black non Hispanics (see Figure 17) and 1.38 preventable hospitalizations for Hispanics. The Prevention Agenda goal is to reduce disparities in the ratios of preventable hospitalizations for black non Hispanics and Hispanics to white non Hispanics by 10%, to 1.85 and 1.38, respectively. Onondaga County has met the Prevention Agenda objective for reducing the disparity of Hispanic to white non Hispanic preventable hospitalizations but still has significant work to reduce the disparity between black non Hispanics and white non Hispanics. Figure 17. Racial and ethnic disparities in preventable hospitalizations, 2008 2010 White non Hispanics Black non Hispanics For every one White non Hispanic preventable hospitalization, there are 2.5 black non Hispanic preventable hospitalizations Source: http://www.health.ny.gov/prevention/prevention_agenda/2013 2017/indicators/2013/onondaga.htm 27

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Access to Care Ninety percent of Onondaga County adults report having a regular health care provider and 92.8% report having health care coverage. These rates are higher than those reported for NYS as a whole, 84.9% and 83.3%, respectively. Despite a relatively high level of access to care, Onondaga County adults are less likely to have had a checkup within the past 12 months (66.9%) compared to NYS (71.2%) and more likely to report 14 or more days of poor physical health in the past month (15.4%) compared to NYS (12.1%) (Expanded BRFSS Preliminary Report, 2013 2014). Summary of Improving Health Status and Reducing Health Disparities At the county level, Onondaga fared better than NYS with respect to the baseline Prevention Agenda indicators for improving health status and reducing health disparities. However, as illustrated by the life table analyses in Figures 15 and 16, the County still faces considerable challenges with respect to achieving health equity through reducing disparities. In addition, more Onondaga County adults report poor physical health. To gain a deeper understanding of the health status of Onondaga County residents, data are presented below from each of the five Prevention Agenda Priority Areas. 28

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Prevention Agenda Area: Preventing Chronic Disease A comprehensive table of health indicators related to chronic disease is presented in Appendix 1.a. The section below highlights areas of interest in the domain of chronic disease for Onondaga County. Cardiovascular Disease Cardiovascular disease includes all diseases of the heart, coronary artery disease, and vascular diseases. Onondaga County enjoys a high standard of care for diseases of the heart and coronary heart disease. Mortality and hospitalization rates for these conditions are statistically significantly lower than NYS and the U.S. In 2005, as heart disease mortality rates decreased more rapidly than cancer mortality rates, the leading cause of death shifted from heart disease to malignant neoplasms in Onondaga County. Currently in Onondaga County mortality due to coronary heart disease is 103.8 per 100,000, approaching the Healthy People 2020 target of 100.8 per 100,000. Overall rates are seen in Figures 18 and 19. Figure 18. Age adjusted mortality for diseases of the heart, 2009 2011 Sources: NYSDOH County Health Indicators, Cardiovascular Disease, http://www.health.ny.gov/statistics/chac/indicators/chr.htm Healthy People 2020 http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=21 National Center for Health Statistics http://www.cdc.gov/nchs/fastats/deaths.htm 29

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Figure 19. Age adjusted mortality for coronary heart disease, 2009 2011 Sources: NYSDOH County Health Indicators, Cardiovascular Disease, http://www.health.ny.gov/statistics/chac/indicators/chr.htm Healthy People 2020 http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=21 National Center for Health Statistics http://www.cdc.gov/nchs/fastats/deaths.htm Cancer In Onondaga County, the incidence of all cancers is increasing. However, as seen in Figure 20, mortality associated with cancer is decreasing. Presumably these differences are attributable to improvements in screening, and thus an increase in early detection of cancer, as well as to improvements in cancer treatment. Each week, approximately 52 Onondaga County residents are diagnosed with cancer and approximately 19 die from cancer. 30

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Figure 20. Age adjusted incidence and mortality rates for all types of cancer in Onondaga County, 1994 2008 Source: http://www.acscan.org/ovc_images/file/action/states/ny/ny_cancer_burden_report_2012.pdf Note: Rates are age adjusted to the 2000 U.S. Standard Population The incidence rates of three common cancers (breast, lung, and prostate) are illustrated in Figure 21. The incidences of both lung cancer and prostate cancer are statistically significantly higher in Onondaga County compared to NYS and the U.S. Figure 21: Incidence of breast, lung and prostate cancers in Onondaga County, New York State, and the U.S., 2007 2009 250.0 Rate per 100,000 200.0 150.0 100.0 132.4 126.9124.3 Onondaga NYS U.S. 83.6 63.8 62.6 216.8 166.9 154.8 50.0 0.0 Breast Lung Prostate Source: http://seer.cancer.gov/csr/1975_2009_pops09/browse_csr.php?section=36&page=sect_a_table.03.html NYSDOH County Health Assessment Indicators, Cancer, 2007 2009 http://www.health.ny.gov/statistics/chac/chai/docs/can_31.htm Note: Rates are per 100,000, age adjusted to the 2000 U.S. Standard Population 31