ECHO Report_Revision 9-2015

HEALTHY PEOPLE CONNECTEDTO A THRIVING COMMUNITY.

August 11, 2015Dear ECHO Steering Committee Members,I would like to take this opportunity to thank you for your continued commitment to EnergizingConnections for Healthier Oakland (ECHO). Your participation is invaluable in this inaugural initiativeto engage the community in a comprehensive method to impact health in Oakland County. Yourefforts and your voice ensure ECHO decisions are enriched by the unique perspective that you bringto the process.Today you will hear the final reports and recommendations from each of the four assessment teamsthat have been engaged in gathering quantitative and qualitative information to build a picture ofhealth in Oakland County. These reports conclude a year of thoughtful deliberation and activitiesto gather data from a variety of sources using numerous methodologies. Our assessment teams,which many of you took part in, are to be congratulated for their hard work and perseverance. I amlooking forward to hearing your viewpoints as the Steering Committee collectively identifies themost pressing issues arising out of these reports and impacting the health of Oakland County.Thank you for taking the time out of your busy schedules to attend this meeting, which marks apivotal point for the ECHO Steering Committee. With data in hand, we can now lay a solid foundationfor the Oakland County Community Health Improvement Plan, which will drive policies and strategiesto achieve your vision of healthy people connected to a thriving community.Thank you for your enthusiastic support in advancing health in Oakland County!Very sincerely,OAKLAND COUNTY HEALTH DIVISIONDepartment of Health and Human ServicesKathleen Forzley, R.S., M.P.A.Manager/Health Officer

NOTES:

COMMUNITY HEALTHSTATUS ASSESSMENT

COMMUNITY HEALTH STATUS ASSESSMENT COMMITTEE MEMBERSACCESS Oakland County CommunityWhitney Litzner Mental Health Authority Nicole LawsonAffirmationsLydia Hanson Oakland County Health Division Anne NiquetteAlliance of Coalitions for Healthy CommunitiesJulie Brenner Oakland County Health Division Shane BiesBaldwin CenterD.J. Duckett Oakland County Health Division Shannon BrownleeBeaumont Health SystemBelinda Barron Oakland County Health Division Adam HartBeaumont Health SystemMaureen Husek Oakland County Health Division Jeff HickeyBeaumont Health SystemErin Wisely Oakland County Health Division Carrie HribarCommon GroundEmily Norton Oakland County Health Division Nicole ParkerEaster SealsStephanie Wolf-Hull Oakland County Health Division Lisa McKay-ChiassonMeridian/Community Programs, Inc.Erica Clute Oakland County Health Division Leigh-Anne StaffordMichigan Department of Health & Human ServicesJill R. Anderson Oakland County Health Division Kim WhitlockMichigan Department of Health & Human ServicesKelly Cutean Oakland Family Services Justin RinkeMichigan Department of Health & Human ServicesVicki Cooley Oakland Schools Christina HarveyMichigan State University ExtensionOakland County St. John Providence Health SystemNancy Hampton Jerry Blair2 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENTEXECUTIVE SUMMARYThe Community Health Status Assessment (CHSA) committee organized in May 2014 to begin a six-step processfocused on examining health in Oakland County. For twelve months, the CHSA committee, comprised of 28individuals representing various community sectors, worked to identify, compile, and analyze data describing healthstatus, quality of life, risk factors, and demographic and socioeconomic characteristics in the County.Represented sectors included: behavioral health, cooperative extension, education (K – 12 and university level),health and human service agencies, healthcare providers, hospitals, public health, and substance use disorderprevention and treatment. The CHSA committee researched over 379 health indicators, identified benchmarksfor over 75 indicators and 144 indicators were utilized to complete the CHSA. Committee efforts resulted in theselection of six strategic themes, over 40 indicators and seven key recommendations to address challenges andopportunities identified during the CHSA process.ECHO OVERVIEWEnergizing Connections for Healthier Oakland (ECHO) is the County’s comprehensive, community-wide healthassessment and improvement planning process. The Oakland County Health Division created the ECHO initiativeto engage the community in a recurring process to:1. Identify – gather data to create a snapshot of health in the county2. Prioritize – rank health issues and determine which ones to address3. Act – develop a coordinated action plan to empower all partners throughout the community to help improve the health of the countyThe ECHO Steering Committee is a cross-sector collaborative with representatives from over 30 partner agencies,including hospitals, higher education, behavioral health organizations, emergency response, businesses, humanservices, environmental organizations, elected officials, parks and recreation, and homeless shelters. The SteeringCommittee’s vision of healthy people connected to a thriving community guides decision-making, while a nationalmodel, Mobilizing Action through Planning and Partnerships (MAPP), is utilized for a planned approach to improvehealth and quality of life. MAPP was developed by the National Association of County and City Health Officials(NACCHO) to help communities apply strategic thinking to prioritize public health issues and identify resources toaddress them. At the end of this process, ECHO will have a comprehensive picture of health in Oakland County thatincludes input from community members, as well as a community health improvement plan developed collectivelywith partners. CHSA • August 2015 3

Each assessment in MAPP answered different questions about the health of a community. Conducting the Community Health Status Assessment involved identifying quantitative data for Oakland County and answering the following overarching questions: • What health conditions exist in the community? • How healthy is the community? • What does the health status of the community look like? METHODOLOGY Prepare for the CHSA: Preparation for the CHSA was completed predominately by a core workgroup comprised of Oakland County Health Division staff with input from an expert consultant in the field of health data analysis. Preparation involved reviewing and modifying processes other jurisdictions across the nation utilized for completing their CHSA. The core work- group utilized this information to develop a CHSA process to meet local community needs. Individuals attended an initial meeting for the CHSA committee to learn about the committee’s purpose and discuss any questions about the CHSA. Those interested completed a survey onsite to describe their experience with health data and information. The information gathered at this meeting was utilized to develop an implementation plan for the six-step process the committee would use (see below). 1. Establish a committee and plan the process 2. Collect data for the core indicators on the CHSA indicator list 3. Select additional data indicator(s) to explore issues important to the community 4. Organize and analyze the data, present information in understandable charts and graphs, and compile findings and disseminate in the community 5. Establish a system to monitor indicators over time 6. Identify challenges and opportunities related to health status for consideration in next phase4 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENTCollect, Organize and Analyze DataFor the CHSA data review and indicator selection, MAPP’s eleven broad-based core (see Appendix A) and extendeddata categories (see Appendix B) were used. The data categories measure health or related contributing factorsthat potentially affect community health status. Utilizing the MAPP core indicators was important because theycross-reference with other initiatives. These indicators include the 25 recommended indicators in the Institute ofMedicine’s report, “Improving Health in the Community” and the majority of indicators from the Centers for DiseaseControl and Prevention (CDC) Community Health Status Indicators web application.The CHSA committee infrastructure evolved into three data groups, making the task to investigate indicators moremanageable. CHSA committee members self-selected into one of the three data groups. Each data group hadcore and extended indicator lists assigned to them as described below. Each group brainstormed data sources andutilized those sources and the ECHO Dashboard to begin identifying and compiling data.Data Group 1: Who are we and what do we bring to the table?1. Demographic and socioeconomic characteristics2. Health status3. Health resource availabilityData Group 2: What are the strengths and risks in our community that contribute to health?4. Quality of life5. Behavioral risk factors6. Environmental health indicatorsData Group 3: What is our health status?7. Social and mental health8. Maternal and child health9. Death, illness and injury10. Infectious disease11. Sentinel events CHSA • August 2015 5

METHODOLOGY (CONTINUED) A series of interactive presentations from local and regional presenters was provided to support the data-related tasks addressed by the committee. The presentation topics provided are listed below: • Community Health Indicator Presentation CHSA and CTSA committees jointly received this presentation from Gary Petroni, Director of the Center for Population Health, Southeastern Michigan Health Association. Committee members had varying degrees of experience and exposure to data and conceptualization of how data are related. This presentation was intended as a starting point for both committees to begin the assessment process. The presentation provided secondary data and information from health needs assessments recently completed targeting substance abuse-related data. Data were reviewed on demographics, behavioral risks, traffic crashes, hospitalization data, and mortality. Discussion was guided by the concepts and questions that included: • Demographics are destiny • All health is local • Wealth equals health • Place matters • Data Sources and Using Quantitative Data for the CHSA This presentation, provided by Nicole Parker, Epidemiologist, Oakland County Health Division (OCHD), served to begin discussion about sources of data the CHSA committee could use and to delineate the difference between primary and secondary data sources. Additionally, the committee received an interactive presentation of the ECHO Dashboard, which is an online resource where Oakland County data is organized and available for dissemination and monitoring. • Benchmarking: What is it? This presentation, provided by Nicole Parker, Epidemiologist, OCHD, occurred after the committee had researched and compiled data for the core and extended indicators from the MAPP model. The focus was to expose the committee to the definition of benchmarks, how to benchmark and benchmark sources. • Health Disparity and Health Equity, Things to Consider This presentation, provided by Shannon Brownlee, Public Health Educator III, OCHD, introduced the concepts of health disparity and equity, the social determinants of health and addressing these issues through prevention efforts. Committee meetings included a component for the data groups to identify data sources for their indicators, assign indicators to group members to research, and discuss gaps and challenges encountered. Written group guidelines were provided as well as written “homework” assignments. Over time, it became evident additional assistance was6 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENTneeded to identify and compile indicators. As a result, three interns supported the work of the CHSA, one providedby a hospital partner to data group 1 and two from OCHD, the convening organization of ECHO.In between meetings, committee members completed tasks related to the presentation topic to practice using theconcepts and data sources presented. As the committee progressed, the members’ tasks involved identifying andcompiling data for sharing at the next meeting. The committee, through general consensus, agreed on the format tocompile the data and agreed to an excel spreadsheet for each data category.Each data category table evolved over time to include benchmarks, multiple years of data when available,data sources and indicator definitions. Category tables were then separated by indicators with and without data.Benchmarks were identified for the indicators with data. Only indicators with benchmarks were considered by theCHSA committee for the analysis process.The CHSA committee utilized numerous state and national data sources to research, compile and analyze indicatorsfor the data category lists. The most commonly used sources are listed below:• Centers for Disease Control and Prevention http://www.cdc.gov/• Community Commons http://www.communitycommons.org/• ECHO Dashboard http://oakland.mi.networkofcare.org/ph/• Health Indicator Warehouse http://www.healthindicators.gov/Indicators/• Michigan Department of Community Health, Health Statistics and Reports http://www.michigan.gov/mdch/0,4612,7-132-2944---,00.html• Michigan Department of Licensing and Regulatory Affairs http://michigan.gov/lara• Michigan State Police http://michigan.gov/msp• National Vital Statistics System http://www.cdc.gov/nchs/nvss.htm• Oakland County Health Division, Communicable Disease Unit• US Census Bureau/American Community Survey http://www.census.gov/• United States Department of Agriculture http://www.usda.gov/Over 379 core and extended indicators were researched during the CHSA process by the data groups. Over 75indicators from all the data category lists did not have any data the groups could locate. When available, an alternate,but related indicator was used as a replacement. For instance, the adolescent pregnancy rate on the core data listdefined adolescent as 15 – 17 years old, but the data available was for teens 15 – 19 years old.Overall, 144 indicators were utilized to describe community health status in Oakland County. Within this group,benchmarks were identified for over 75 indicators. The committee data groups discussed the importance of missinginformation and identified recommendations to address the gap, including conducting data collection in the futureand recommending action to the Steering Committee (see results section). CHSA • August 2015 7

METHODOLOGY (CONTINUED) Benchmarking was completed with the following prioritization for utilizing available benchmarks: • Healthy People 2020 (HP2020) Objectives for the nation target measures • State of Michigan indicators • United States indicators • Oakland County Health Division, ten-year average of communicable disease data If HP2020 targets were not available, the State of Michigan indicators were used as a benchmark. The United States was used as a benchmark for nine indicators. As a group, the committee reviewed all eleven data category spreadsheets and completed the comparison of indicators to benchmarks using the following definitions: • Better than the benchmark by at least 2 points • About the same as the benchmark +/- 1 point • Worse than the benchmark by at least 2 points This was followed by sorting the results of this comparison into three groups (see below). • Better than the Benchmark • About the Same • Worse than the Benchmark Results of benchmarking were distributed to committee members to identify strategic themes comprised of related indicators. Themes were finalized through a multi-step process listed below: • Group discussion: A discussion regarding what is a theme and examples of themes from the Forces of Change and Community Themes and Strengths Assessments and MAPP resources were shared with the committee. • Diagram strategic-related indicators and identify strategic themes: Working independently, committee members diagrammed relationships between indicators and created a potential strategic theme using a handout provided (see example on next page). Committee members were also asked to select 8 – 10 indicators that they believed were important to maintain and/or improve to assist them in organizing indicators into theme groupings.8 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENTExample Indicator/Theme DiagramSeat Belt Use Substance AbuseHealthy Eating Theme: Healthy Living Physical Activity Fruit/Veggie Consumption• Review and edit indicator/theme relationships: Suggested themes and related indicators were compiled from committee member’s independent efforts. In pairs, committee members reviewed this information to determine if the indicators and themes made sense and, if not, made suggested deletions, additions, or edits.• Finalize themes and associated indicators: As a group, the committee discussed all the suggested changes made to the themes and indicators and made a final list for voting. Through consensus, fourteen themes were narrowed to seven by combining and deleting themes and associated indicators.RESULTS: BENCHMARK COMPARISONSThe CHSA committee narrowed 379 indicators down to a list of 75 indicators with benchmarks. The benchmarkingcomparison process resulted in the indicators being grouped as listed below (see Appendix C for the listing ofindicators and the benchmark groupings):• 36 indicators were better than the benchmark by at least two points• 19 indicators were about the same as the benchmark by +/-1 point• 19 indicators were worse than the benchmark by at least two points CHSA • August 2015 9

RESULTS: FINALIZING THEMES AND INDICATORSA multi-step process involving individuals, committee members working as pairs, and group efforts narrowed a listof 14 themes and 58 indicators to a list of 7 themes and 45 indicators. The committee voted on this to select thefinal themes and indicators.Recommendation: The themes and indicators selected by the committee are shown below and are beingrecommended to the ECHO Steering Committee for consideration in the Identifying Strategic Issues phase.RESULTS: SIX-THEME INDICATOR ANALYSESTop Six Voted Theme Indicator Relationships: CHSA Built Environment Teen/Adult Health Healthy Eating Grocery Store Rate Healthy Eating Fruit & Veggie ConsumptionRec & Fitness Facility Access Suicide Prevention Fast Food Restaurants Obesity Food Deserts Physical Activity Salmonella Food Access Seat Belt Use Food Deserts Fast Food Restaurants Sexual Behavior Liquor Store Rate Drug/Alcohol/Tobacco Use Healthy Living Vaccine-Preventable Disease Maternal & Child Health Drug Use Pneumonia No Prenatal Care Tobacco Use MMR Healthy Food Access Alcohol Use Neo/Post Neo Mortality Seat Belt Use PertussisFruit & Veggie Consumption Imms- Adult Low Birth Rate Physical Activity Imms- Kids Entrance to Prenatal Care Obesity Hep B Low Birth Weight Hep A % Gained During Pregnancy Infant Mortality Teen Birth10 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENTTo understand the current measure of each indicator within the six recommended themes, results are depicted inthe graphs and tables that follow. The six themes are:• Built Environment• Healthy Living• Healthy Eating• Teen/Adult Health• Vaccine-Preventable Disease• Maternal and Child HealthRESULTS: BUILT ENVIRONMENTBeing healthy depends on many factors such as having access to healthy food, clean air and water, and opportunitiesfor regular physical activity. When these are easily accessible in the communities where we live, work and play,achieving good health is more attainable.The indicators analyzed for the built environment theme are a starting point. Research to locate additionalinformation describing the built environment as it impacts physical activity, travel within a community and otherinfrastructures will occur. Indicators and information documenting parks, trails, sidewalks and safety issues willprovide a more comprehensive perspective of the built environment. Built Environment 2008-2012Percent Population 70% Oakland County Michigan United States 60% 50% Data Source: U.S. Census Bureau, American 40% Community Survey, 2008-2012, USDA Food Access 30% Research Atlas. The mRFEI indicator reports the 20% percentage of population living in census tracts with 10% no or low access to healthy food stores. 0% Population Population Living Use Living in Food with no or Low of Public Desert Healthy Food Access Transportation CHSA • August 2015 11

RESULTS: BUILT ENVIRONMENT (CONTINUED)Although Oakland County has a larger percentage of the population living in a food desert compared to Michiganand the US, the county has greater access to food retailers selling healthy foods as measured by the modifiedretail food environment index. Use of public transportation in Oakland County is lower than that of Michigan and theUnited States. Lack of contiguous public transportation from one community to another contributes to this result. Built Environment Continued Oakland County Michigan United States 120Rate per 100,000 100 80 60 40 20 0 GNroucmerbyeSr toofres NLiuqmuobreSr toofreFsitneRsescFreaacitliiotynAacncdessSNFoAoPd-ASutothroerAizcecdess FWoIoCd-ASutothroerAizcecdess Number of FRaeststFaouoradntsData Source: U.S. Census Bureau; County Business Patterns; CDC Division of Nutrition, Physical Activity, and Obesity; USDAFood Access Research Atlas; USDA SNAP Retailer Locator; American Community Survey; USDA Food Environment AtlasThe CHSA committee viewed access to healthy food and beverages as a critical component of the built environment,as well as access to recreation and fitness opportunities. Oakland County exceeded the rate of fast food restaurantsas compared to Michigan and the US. Similarly, Oakland County has more liquor stores than Michigan and the US.When reviewing the rate per 100,000 of grocery stores and SNAP-authorized food stores, Oakland County issimilar to Michigan and the US. For WIC-authorized food stores, Oakland County is similar to the US and lower thanMichigan. Having access to recreation and fitness opportunities is important for physical activity. Oakland Countyhas slightly greater access than Michigan and the US.12 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENTRESULTS: HEALTHY LIVINGHealthy Living is about making healthy choices every day - healthy choices that keep people fit physically, mentallyand spiritually. Eating well, being physically active, and not smoking are three of the best things to do to stay healthy,prevent chronic diseases, and reduce the risk of becoming ill or seriously injured.Everyone has a role to play in supporting healthier living. Individuals, families, communities, governments andother organizations can work together to create environments and conditions that support healthy living. Someexamples include creating smoke-free public spaces, making nutritious foods easily accessible or developingcommunities and buildings that promote physical activity. Healthy Living 2011 - 2013100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Adult Fruit No Leisure Adults Adults Who Adults (aged Seatbelt Use Adult Obesity and Vegetable Time Physical Currently Binge Drink 18+) that Report Consumption Smoking Heavy Drinking Activity Oakland County Michigan HP2020Data Source: Behavior Risk Factor Surveillance System, Michigan Department of Community Health; 2011-2013 CHSA • August 2015 13

RESULTS: HEALTHY LIVING (CONTINUED)Over 20 million Americans live in food deserts – urban neighborhoods and rural towns without ready accessto fresh, healthy, and affordable food. This lack of access contributes to a poor diet and can lead to higher levelsof obesity and other diet-related illness such as diabetes and heart disease. Many of these communities thatlack healthy food retailers are also over-saturated with fast food restaurants, liquor stores, and other sources ofinexpensive, processed food with little to no nutritional value. Oakland County has a much greater number of fastfood restaurants per 100,000 population at 82.17 than Michigan at 66.61. Healthy Eating Fast Food Restaurants 0 10 20 30 40 50 60 70 80 90Data Source: U.S. Census Bureau, Oakland County MichiganCounty Business Partners Rate per 100,000 Healthy Eating ContinuedPercent Population 40% 35% 30% 25% 20% 15% 10% 5% 0% Population Living in Food Adult Fruit and Vegetable Adults Who are at a Obese Adults Desert (low food access) Consumption (2011-2013) Healthy Weight (2011-2013) (2011-2013) (2012)Data Source: Behavior Risk Factor Surveillance System, Oakland County Michigan HP2020Michigan Department of Community Health.USDA - food Access Research Atlas14 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENTWhen examining people who live in food deserts, Oakland County has a higher percentage of those with low foodaccess (30.91%) than the state of Michigan (23.05%). Oakland County fares better than the state for the percentageof adults reporting fruit and vegetable consumption (20.6% vs 16.6% respectively). Oakland County (38%) exceedsthe HP2020 benchmark (34%) and Michigan (33%) for adults at a healthy weight and with less obese adults, at25.7% vs. 30.5% vs. 31.3% respectively.RESULTS: TEEN HEALTH INDICATORSPromoting health and wellness in adolescents helps them become healthy productive adults. Certain behaviorsand conditions can put teens at risk for health-related problems in adulthood. Emerging information and data isbeginning to focus on factors that are protective for children and youth and will be important to incorporate intofuture community health status assessment endeavors.The following graphs are from the Michigan Profile for Healthy Youth (MiPHY) survey facilitated by the MichiganDepartment of Education. Because only eight Oakland County school districts participated in the survey, thisinformation is not recommended to generalize to the overall teen population in Oakland County. However, theinformation is valuable to monitor how teen health changes over time and compares to the Healthy People 2020objective targets for the nation. Teen Healthy Lifestyles 2013-2014Percent Students 70% 60% 50% Teens Who are Obese Teens Who are Overweight Teens Who Engage in Regular 40% Physical Activity - 60 Min/Day 30% MiPHY Oakland HS MiPHY 11th Grade 20% MiPHY Oakland MS MiPHY 7th Grade MiPHY 9th Grade 10% HP2020 0%Data Source: Michigan Profile for Healthy Youth, 2013-2014 CHSA • August 2015 15

RESULTS: TEEN HEALTH INDICATORS (CONTINUED)Fewer teens in Oakland County are obese than the HP2020 benchmark of 14.50%, according to those participatingin the MiPHY survey from middle schools in 8 districts and high schools in 9 districts. Ten percent of middle schoolstudents and 11.40% of high school students participating in the survey were obese. More students in middle andhigh school report engaging in regular physical activity as compared to the HP2020 benchmark of 31.6%. Teen Health Behaviors 2013 - 2014Percent Students 80% 70% 60% 50% 40% 30% 20% 10% 0% Ever Had Sexual Drank Alcohol or Used a Condom During Never or Rarely Wore a Intercourse Used Drugs Before Last Last Sexual Intercourse Seat Belt when Riding in a Car Driven by Someone Else Sexual Intercourse MiPHY Oakland HS MiPHY 11th Grade MiPHY 9th Grade MiPHY Oakland MS MiPHY 7th GradeData Source: Michigan Profile for Healthy Youth, 2013-2014 In Oakland County, more high school students compared to middle school students participating in the MiPHY survey were sexually active, drank alcohol or used drugs before last sexual intercourse and used a condom during sexual intercourse. More middle school students wore a seat belt when in a car driven by someone else than high school students.16 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENT Teen Mental Health 2013 - 2014Percent Students 35% 30% 25% Felt Sad or Hopeless Seriously Considered Actually Attempted Suicide One 20% Attempting Suicide or More Times 15% 10% 5% 0% MiPHY Oakland HS MiPHY 11th Grade MiPHY 9th Grade MiPHY Oakland MS MiPHY 7th GradeData Source: Michigan Profile for Healthy Youth, 2013-2014More high school students compared to middle school students in Oakland County reported feeling sad or hopelessand slightly more had attempted suicide one or more times in the past. A similar percentage of students in both highschool and middle school reported seriously considering suicide. CHSA • August 2015 17

RESULTS: TEEN HEALTH INDICATORS (CONTINUED) Teen Substance Use 2013 - 2014 70% 60%Percent Students 50% 40% 30% 20% 10% 0% Smoked Cigarettes on Smoked a Ever Drank Alcohol Had a Drink of Used Marijuana Took a Prescription Took Painkillers such 20 or More of Cigarette Recently in their Lifetime Alcohol Recently (One or More Times Drug Such a Ritalin, as OxyContin, Codeine, in the 30 Days Prior Adderall, or Xanax the Past 30 Days without a Doctor’s Vicodin, or Percocet (Frequent) to this Survey) Prescription in the without a Doctor’s Prescription in the Past 30 Days Past 30 Days MiPHY Oakland HS MiPHY 11th Grade MiPHY 9th Grade MiPHY Oakland MS MiPHY 7th Grade HP2020Data Source: Michigan Profile for Healthy Youth, 2013-2014More high school students reported smoking cigarettes and marijuana, drinking alcohol, and taking prescriptiondrugs without a doctor’s prescription than middle school students in Oakland County who took the survey. OaklandCounty high school students exceeded the Healthy People 2020 benchmarks in all areas of teen substance abuseexcept smoked a cigarette recently.18 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENTRESULTS: ADULT HEALTHHealth is a state of complete physical, mental, and social well-being and not merely the absence of disease. Healthstarts in our homes, schools, workplaces, neighborhoods, and communities. We know that taking care of ourselvesby eating well and staying active, not smoking, getting the recommended immunizations and screening tests, andseeing a doctor when we are sick all influence our health.The health needs of adults are very different from teens and children. Needs vary throughout life and are greatlyinfluenced by whether you are in a stage of growth and development or maintenance. Children and teens requiremore energy and nutrients to build new muscles, bones and skin, while adults’ needs are influenced by many factors,including gender and physical activity level. Adult Health 2011 - 2013101000%% 9090%% 8080%%Percent Population 7070%% Percent Population 6060%% 5050%% 4040%% 3030%% 2020%% 1010%% 00%% Adult Fruit and Vegetable No Leisure Time Physical AAdduultlstsC- Cururerrnetnlyt Smokingg Binge Drinking - Adults Who Adults (aged 18+) that Seat Belt Use Consumption Activity Binge Drink Report Heavy Drinking Oakland Michigan HP2020 Oakland County Michigan HP2020Data Source: Behavior Risk Factor Surveillance System, Michigan Department of Community Health; 2011-2013Oakland County adults 18 years or older reported higher fruit and vegetable consumption (20.6%) than adultsstatewide in Michigan (16.6%). In comparison, Oakland County adults were slightly better (20.6%) than Michigan(23.8%) and the HP2020 benchmark (32.6%) for no leisure time physical activity. Oakland County and Michiganwere both at 89% for seat belt use, which is somewhat less than the HP2020 benchmark of 92%. CHSA • August 2015 19

RESULTS: VACCINE-PREVENTABLE DISEASEImmunizations have had an enormous impact on improving health in the United States. Most parents todayhave never seen first-hand the devastating consequences that vaccine-preventable diseases have on a family orcommunity. While these diseases are not common in the U.S., they persist around the world. It is important that wecontinue to protect our children and adults with vaccines because outbreaks of vaccine-preventable diseases canand do occasionally occur in this country.Vaccination is one of the best ways parents can protect infants, children, and teens from 16 potentially harmfuldiseases. Vaccine-preventable diseases can be very serious, may require hospitalization, or even be deadly –especially in infants and young children. Vaccine-Preventable Disease 2009 - 2013Rate Per 100,00 2525 2020 1515 Mumps Rubella Pertussis HHeeppaattititisisAACcaasseess Hepatitis B Cases 1010 55 00 Measles Oakland County OCHD 10-Yr Crude Rate HP2020 Data Source: Michigan Disease Surveillance System (MDSS) 2009-2013 case counts for Oakland County. Crude 10-year annual rate per 100,000 calculated using 2010 census estimates. From 2009 – 2013, Oakland County experienced no cases of measles and rubella and a low occurrence of mumps and Hepatitis A. Pertussis cases were higher from 2009 – 2013 compared to a 10-year crude rate average in Oakland County 2004 – 2013.20 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENT Vaccine-Preventable Disease 2006 - 2012Percent Population 101000%% 9090%% 8080%% APdrouplotsrtiaongeofdad6u5lt+s aimgemd 6u5n+iziemdmiunnipzeadsitn1p2asmt 1o2nmthonsthfsorfoirnIfnlfulueennzzaa APdruopltosrtaiogneodf a6d5u+ltsiamgmedu6n5iz+eimdminunpizaesdt i1n2pamsto1n2tmhsonftohrs pfonrepunemuomcoococcccaall ppnneeuummonoiania 7070%% 6060%% 5050%% 4040%% 3030%% 2020%% 1010%% 00%% Oakland County HP2020Data Source: Health Indicators Warehouse 2006 – 2012Sixty-seven percent of adults aged 65+ were immunized in the past 12 months for influenza, which is slightly lowerthan the HP2020 benchmark of 70%. In comparison, the proportion of adults aged 65+ immunized in the past12 months for pneumococcal pneumonia (67%) was much lower than the HP2020 benchmark of 90%.RESULTS: MATERNAL AND CHILD HEALTHA healthy and safe motherhood begins before conception with good nutrition and a healthy lifestyle. It continues withappropriate prenatal care and preventing problems before they arise. Pregnancy and childbirth have a significantimpact on the physical, mental, emotional, and socioeconomic health of women and their families. Pregnancy-related health outcomes are influenced by a woman’s health and other factors like race, ethnicity, age, and income.The ideal result is a full-term pregnancy without unnecessary interventions, the delivery of a healthy baby, and ahealthy postpartum period in a positive environment that supports the physical and emotional needs of the mother,baby, and family. CHSA • August 2015 21

RESULTS: MATERNAL AND CHILD HEALTH (CONTINUED) Maternal and Child Health - 2012 5500 4455 4400 3355Rate Per Live Births 3300 2255 2200 1155 1100 Estimated teen Neonatal mortality Post neonatal Live birth rate Inadequate pregnancy mortality prenatal care 55 00 Infant mortality Oakland County Michigan HP2020 Data Source: Michigan Department of Community Health, 2012 Michigan and Oakland County have a slightly higher infant mortality rate than the HP2020 benchmark of 6 deaths per 1,000 live births. Oakland County (28.3) has a much lower teen pregnancy rate than the HP2020 benchmark (36.2) and Michigan (45.5). Oakland County has a lower rate of inadequate prenatal care than Michigan at 6.6 and 8.3 respectively. Oakland County has a higher birth rate at 10.9 per 1,000 population compared to Michigan at 6.9 per 1,000 population.22 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENT MaterMnalaantdeCrhnilad Hl e&althC- 2h0i1l2d Health90.009%0%80.008%0%70.007%0%60.006%0%Percent50.005%0% 40.004%0% 30.003%0% 20.002%0% 10.001%0% 0.00%0% WWeeiigghht tgaginaeidnwehdilewhile LLiivveebibrthirstwhisthwprietnhatal ModMiofdieifidedRReettaaililFoFoodod LowLobwirbtirhth wweeigightht pprereggnnaannt ftorfosirngsleintognleton cparree nbeagtinanlincgairnethe EnvEirnovniromnmeenntt IInnddexe*x* (Ke(KsessnsenerrIInnddeexx) ) mmoommsswawsaesxceexssciveessive beginnfiirnstgtriimnetshteer first trimester Oakland County Michigan HP2020Data Source: Michigan Department of Community Health, 2012. The mRFEI indicator reports the percentage of population livingin census tracts with no or low access to healthy food stores.Oakland County has a larger percentage (85.2%) of live births with moms who began prenatal care in their firsttrimester of pregnancy compared to Michigan (74.3%) and the HP2020 benchmark (77.9%). Michigan (51.0%) andOakland County (52.0%) are both well below the HP2020 target (61.1%) for access to food retailers who sell healthyfoods. Oakland County is somewhat higher than the state for weight gain during a singleton pregnancy at 50.50%compared to 46.30%. CHSA • August 2015 23

RESULTS: HEALTH EQUITYHealth equity is when every person has the opportunity to achieve their highest level of health and no person isdisadvantaged from attaining this because of their social position or other socially determined circumstance. Healthinequities are unfair health differences closely linked with social, economic, or environmental disadvantages thatadversely affect groups of people.Examining measures of social and economic inequities is a first step in understanding health disparity and equityin a community.PPooppuullaati'onoinn P inov  Perotyv–er1t0y0 %  -­‐  1F0P0L:%2 0  F0P8L-  2-­‐ 0  210208  -­‐  2012   NNoont -HHiissppaanniicc / Latino 5% 10% 15% 20% 25% 30% Hispanic / Latino Multiple Races Some Other Race Native Hawaiian / Pacific IslanderNon-HNiosnpa-HnicspAamneicriAcamneIrnicdaiann I/nAdliasnk/aAn lNasaktiavne NatiNveon-Hispanic Asian Non-Hispanic Black Non-Hispanic White Oakland County Total 0%Data Source: US Census Bureau, American Community Survey. 2008-2012When examining poverty at 100% of the federal poverty level from 2008 – 2012, all racial/ethnic groups except forNon-Hispanic/Latino, Non-Hispanic Asian, and Non-Hispanic White groups experienced disproportionate povertycompared to the Oakland County average of just under 10%. Non-Hispanic Asian and Non-Hispanic White groupswere less than this average at 6.23% and 8.42% respectively while Non-Hispanic/Latinos were about the same asthe average. All other racial/ethnic groups exceeded the average of 9.93% by a range of 17.04% for Non-HispanicAmerican Indian to 23.96% for Hispanic/Latino.24 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENTPoPpouplaul'aotionn  RReececeiviviningg  SSNNAAPP  BBeenneefifits  2-­‐ 0 200808- 2  -­‐ 0  210212   Hispanic / Latino 5% 10% 15% 20% 25% Some Other RaceNon-Hispanic American Indian / Alaskan Native Non-Hispanic Asian Non-Hispanic Black Non-Hispanic White Oakland County Total 0%Data Source: US Census Bureau, American Community Survey. 2008-2012When examining the population receiving SNAP benefits from 2008 – 2012, all racial/ethnic groups except forNon-Hispanic Asian and Non-Hispanic White groups far exceeded the Oakland County average of 9.18%. All othergroups range from 17.58% (Some Other Race) to 20.80% (Non-Hispanic American Indian).UnUenmempploloyymmeenntt  -­2‐  2001133   NNoont-HHiissppaanniicc // Latino 8% 10% 12% Hispanic / Latino Multiple Races Non-Hispanic Asian Non-Hispanic Black Non-Hispanic White Oakland County Total 0% 2% 4% 6%Data Source: US Census Bureau, American Community Survey. 2008-2012When reviewing unemployment rates among populations, Hispanic/Latino, Non-Hispanic Black groups, and MultipleRaces groups were higher than the Oakland County average of 6.60% in 2013 by 3% to 4%. CHSA • August 2015 25

RESULTS: HEALTH EQUITY (CONTINUED) UninUsnuinresdur  PeodpPuolpau/loatnio  -­n‐  2008  -­‐  2012   NNono-tHHiissppaanniicc / Latino Hispanic / Latino Multiple Races Some Other Race Native Hawaiian / Pacific Islander Non-HispNaonni-cHAismpaenriiccaAnmInedriicaann/IAndlaiasnka/nAlNaasktiavne Non-Hispanic Asian Non-Hispanic Black Non-Hispanic White Oakland County Total 0% 5% 10% 15% 20% 25% 30%Data Source: US Census Bureau, American Community Survey. 2008-2012From 2008 – 2012, Non-Hispanic American Indian/Alaskan Native population at 27.26% significantly exceededthe Oakland County uninsured total of 9.81%. This is 2.8 times higher than the county total. The Hispanic/Latinopopulation also had a much higher uninsured population than the county at 22.73%.Population age 25+ with No High School Diploma 2008 - 2012 Popula'on  age  25+  with  No  High  School  Diploma  -­‐  2008  -­‐  2012   Not Hispanic / Latino 5% 10% 15% 20% 25% 30% 35% Hispanic / Latino Multiple Races Some Other Race Native Hawaiian / Pacific IslanderNon-Hispanic American Indian / Alaskan Native Non-Hispanic Asian Non-Hispanic Black Non-Hispanic White Oakland County Total 0%Data Source: US Census Bureau, American Community Survey. 2008-2012When reviewing the population age 25 years or older with no high school diploma from 2008 – 2012, Some OtherRace, Hispanic/Latino and Non-Hispanic American Indian/Alaskan Native groups far exceeded the county total of7.39% at 29.19%, 24.83% and 17.76% respectively.26 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENTRESULTS: HEALTH DISPARITYHealth disparities are often referred to as differences in health conditions and health status between groups. Mosthealth disparities affect groups because of socioeconomic status, race/ethnicity, sexual orientation, gender, disabilitystatus, geographic location, or a combination of these factors. Health Disparity by Gender, Oakland County, Age-Adjusted Rates 2007 - 2011Ischemic Heart Disease OAKLAND MALE FEMALE COUNTY TOTAL 170.11 103.02 131.65Mortality - Cancer 166.1 194.55 148.08Mortality - Heart Disease 192.59 235.38 160.38Mortality - Homicide 4.2 6.87 1.63Mortality - Lung Disease 37.46 40.93 35.35Mortality - Motor Vehicle Crash 3.53 5.44 1.77Mortality - Stroke 36.77 37.34 35.81Mortality - Suicide 10.54 17.16 4.54Mortality - Unintentional Injury 23.94 32.14 17.12Data Source: Centers for Disease Control and Prevention, National Vital Statistics System. Accessed via CDC WONDER. Centersfor Disease Control and Prevention, Wide-Ranging Online Data for Epidemiologic Research. 2007-11. Source geography: County CHSA • August 2015 27

RESULTS: HEALTH DISPARITY (CONTINUED)The table on the previous page illustrates disparities between men and women for both disease and mortality,with men experiencing a predominately larger burden of disease and health-related mortality than women. Whenexamining Ischemic Heart Disease, men experience this disease at a much greater rate than women. Similarly,men account for significantly more deaths due to cancer, heart disease, homicide, motor vehicle crashes, suicide,and unintentional injury than women.RESULTS: RACE/ETHNICITY COMPARISONS DISEASE AND MORTALITYThe graphs below illustrate the distribution of death and disease by race and ethnicity in Oakland County. Overall,the Non-Hispanic Asian population is the healthiest compared to other races and ethnic groups for all types ofmortality and disease shown in the graphs that follow.IschemIsicchHaeeamrtiDc i  Hseeaasret 2  D0i0s7e-a2se01  -­1‐  2•0A0g7e -  -­A‐  2d0ju1s1te  d Rate Age-­‐Adjusted  Rate   Hispanic/Latino 50 100 150 200Non-Hispanic American Indian / Alaskan Native Rate  per  100,000   Non-Hispanic Asian Non-Hispanic Black Non-Hispanic White Oakland County Total 0Data Source: Centers for Disease Control and Prevention, National Vital Statistics System. Accessed via CDC WONDER. Centersfor Disease Control and Prevention, Wide-Ranging Online Data for Epidemiologic Research. 2007-11. Source geography: CountyThe largest burden of heart disease is experienced by the Non-Hispanic American Indian/Alaskan Native andNon-Hispanic Black populations at 178.22 per 100,000 and 175.65 per 100,000 respectively. This compares to65.38 per 100,000 among the Non-Hispanic Asian population.28 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENTHIV Prevalence 2010 • Age-Adjusted Rate Hispanic/Latino Non-Hispanic Black Non-Hispanic White Oakland County Total 0 50 100 150 200 Rate  p2e5r0  100,0003  00 350 400 450 500 Rate per 100,000HIV Prevalence Source: US Department of Health & Human Services, Health Indicators Warehouse. Centers for Disease Controland Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. 2010. Source geography: CountyData Source: Centers for Disease Control and Prevention, National Vital Statistics System. Accessed via CDC WONDER. Centersfor Disease Control and Prevention, Wide-Ranging Online Data for Epidemiologic Research. 2007-11. Source geography: CountyWhen reviewing HIV Prevalence between populations, the Hispanic/Latino rate is 1.3 times higher than the totalOakland County rate. Non-Hispanic Blacks experienced the greatest burden of disease at almost three times higherthan the Oakland County rate of 159.0 per 100,000 and the Non-Hispanic White rate was the lowest at 109.1per 100,000. Heart  Disease  Mortality  -­‐  2007  -­‐  2011   Heart Disease MoArtagleit-y­‐A2d0j0u7st-e2d0  R11at•eA   ge-Adjusted Rate Hispanic/Latino 50 100 150 200 250 300Non-Hispanic American Indian / Alaskan Native Rate  per  100,000   Non-Hispanic Asian Non-Hispanic Black Non-Hispanic White Oakland County Total 0Data Source: Centers for Disease Control and Prevention, National Vital Statistics System. Accessed via CDC WONDER. Centersfor Disease Control and Prevention, Wide-Ranging Online Data for Epidemiologic Research. 2007-11. Source geography: CountyThe Non-Hispanic Black population experienced the largest rate of death due to heart disease at 1.3 times higherthan the Oakland County total, three times higher than the Non-Hispanic Asian population, 1.5 times higher than theHispanic/Latino population, and 1.3 times higher than the Non-Hispanic White population. CHSA • August 2015 29

RESULTS: RACE/ETHNICITY COMPARISONS DISEASE AND MORTALITY (CONTINUED) Cancer  Mortality  -­‐  2007  -­‐  2011,     Cancer MAogreta-­‐lAitydj2u0s0t7ed- 2 R0a1t1e •   Age-Adjusted Rate Hispanic/Latino 50 100 150 200 250Non-Hispanic American Indian / Alaskan Native Rate  per  100,000   Non-Hispanic Asian Non-Hispanic Black Non-Hispanic White Oakland County Total 0Data Source: Centers for Disease Control and Prevention, National Vital Statistics System. Accessed via CDC WONDER. Centersfor Disease Control and Prevention, Wide-Ranging Online Data for Epidemiologic Research. 2007-11. Source geography: CountyWhen examining cancer deaths, the Non-Hispanic Asian rate was significantly lower than the total Oakland Countyrate. The Hispanic/Latino rate was 1.2 times lower than the Oakland County rate while the Non-Hispanic Blackpopulation had the highest rate at 1.2 times higher than the County rate. The remaining population groups wereapproximately the same rate as the total Oakland County rate of 166.1 per 100,000.30 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENT Lung DiLsuenasge  DMisoeratasliety  M20o0r7ta-li2t0y1  -1­‐  2•0A0g7e - -­A‐  2d0ju1s1te   d Rate Age-­‐Adjusted  Rate   Hispanic/Latino Non-Hispanic Asian Non-Hispanic Black Non-Hispanic White Oakland County Total 0 5 10 15 20 25 30 35 40 45 Rate  per  100,000   Data Source: Centers for Disease Control and Prevention, National Vital Statistics System. Accessed via CDC WONDER. Centers for Disease Control and Prevention, Wide-Ranging Online Data for Epidemiologic Research. 2007-11. Source geography: County The Non-Hispanic White population experienced the greatest burden of lung disease deaths compared to all other population groups. The Non-Hispanic Black rate was 1.3 times less than the Non-Hispanic White rate, but was the second highest rate overall. HomHiciodemMicoirdtaelit y M2o00r7ta- l2it0y11  -­‐ •  2A0g0e-7A d -­‐ j  u2s0te1d1R   ate Age-­‐Adjusted  Rate   Hispanic/Latino Non-Hispanic Black Non-Hispanic WhiteOakland County Total 0 2 4 6 Rate8  per  100,10000   12 14 16 18 Data Source: Centers for Disease Control and Prevention, National Vital Statistics System. Accessed via CDC WONDER. Centers for Disease Control and Prevention, Wide-Ranging Online Data for Epidemiologic Research. 2007-11. Source geography: County The Non-Hispanic Black population experienced a much greater amount of death due to homicide at almost four times the county rate, two times the Hispanic/Latino rate, and almost nine times the Non-Hispanic White rate. CHSA • August 2015 31

RESULTS: RACE/ETHNICITY COMPARISONS DISEASE AND MORTALITY (CONTINUED) Stroke MStorrotakleitAy  Mg2e0o-­0‐Ar7tda-jlu2it0syt1 e 1 -­‐ d  2• A0 R0gae7t-e A -­‐   d 2j0us1t1e d   Rate 50 60 Hispanic/Latino Non-Hispanic Asian Non-Hispanic Black Non-Hispanic WhiteOakland County Total 0 10 20 30 40 Rate  per  100,000  Data Source: Centers for Disease Control and Prevention, National Vital Statistics System. Accessed via CDC WONDER. Centersfor Disease Control and Prevention, Wide-Ranging Online Data for Epidemiologic Research. 2007-11. Source geography: CountyThe Non-Hispanic Black population experienced the greatest burden of death due to stroke compared to otherracial/ethnic groups. This rate is almost 1.5 times greater than that of the Non-Hispanic White population, almost1.4 times that of the Hispanic/Latino population and slightly more than 1.3 times greater than the Non-HispanicAsian rate. SuicidSeuMicoirdtaeAli t g Mye2o-­0‐Ar0td7aj-uli2ts0yt1e  1-­‐d  2•  RA0ga0et7-e A  - ­ ‐ d  2ju0s1te1d   Rate Hispanic/Latino Non-Hispanic Asian Non-Hispanic Black Non-Hispanic WhiteOakland County Total 0 2 4 6 8 10 12 14 Rate  per  100,000  The Hispanic/Latino and Non-Hispanic White population experienced a slightly greater amount of death due to suicidethan the overall Oakland County rate and a much higher rate than the Non-Hispanic Black population, who have arate 1.6 times lower than the overall Oakland County rate.32 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENTRESULTS: CHALLENGES, OPPORTUNITIES AND RECOMMENDATIONSStep six in the CHSA process involved identifying challenges and opportunities related to health status, which wererecommended for consideration in the next phase - Identifying Strategic Issues.Recommendation: For the ECHO Steering Committee to review and consider the challenges, opportunities, andsuggestions listed in the table below. The CHSA committee also made suggestions for consideration beyond theIdentifying Strategic Issues phase.GAP CHALLENGES OPPORTUNITIES SUGGESTIONSQuality of Life • Only data for 4 of 29 • Update and expand • Review and delete indicators in this category list indicators outdated indicators • Many indicators outdated • Research different indicators. • Update with new indicators and no longer tracked Look at health equity/ • Research and create new • Defining at a county vs. disparities and other methods to measure data city, village, township level communities using MAPP • Accessing Economic Development and Community Affairs County Data • Lack of data • Survey found through • Research and create new NACCHO MAPP Health methods to measure data Civic Equity resource • Adapt survey in MAPPEngagement Health Equity Resource and implement • Look to resources in NACCHO CHSA MAPP Health Equity/Disparity resourceIndicators with • Revisit indicator definitions No Data and update as needed • Prioritize indicators • Include prioritized indicators in the next community survey CHSA • August 2015 33

RESULTS: CHALLENGES, OPPORTUNITIES AND RECOMMENDATIONS (CONTINUED) GAP CHALLENGES OPPORTUNITIES SUGGESTIONS Indicators • Cannot find the same • Trends – for indicators • Change/modify indicators without definition without benchmarks, • Look at peer counties • No benchmark means complete trending and nationwideBenchmarks no comparison categorize by: • Look at other counties’ • Peer counties might be too o Trending in a healthy health assessments in Teen small to compare direction NACCHO MAPP CHSAHealth Data o Trending in an unhealthy resource list direction • Monitor Teen Health • Small sample size for • Categorize trends by: • Explore oversampling of MiPHY so cannot generalize o Trending in a healthy Oakland County for logistics to County direction and cost • YRBS state level and county o Trending in an unhealthy • Encourage schools to youth could be different than direction participate in MiPHY survey state level data • Project Aware at Oakland Schools includes an objective to increase the number of schools participating in MiPHY Health • Data readily available by • Utilize the existing data when • Discuss health disparity/Disparity gender & race prioritizing themes and equity earlier on in the process • Other analyses require completing the Community • Consider information Health technical expertise and Health Improvement Plan presented in results section Equity locating other indicators to address all themes during selecting strategic issues phase PlaceMatters • Data compilation initiated for • Explore other recommended • Discuss health disparity/equity easily accessed indicators indicators and mapping from earlier in the process • Other analyses require the MAPP health equity/ • Consider information technical expertise and disparity document presented in results section locating other indicators during selecting strategic issues phase • Committee self-defined this • Opportunity to explore social • Look at other counties’ health theme and need to cross justice issues assessments in NACCHO reference with reputable • Use data found for health MAPP CHSA resource list sources impact assessment • Research through other reputable sources34 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENTRESULTS: SUMMARY RECOMMENDATIONS FROM THE CHSA COMMITTEERecommendation #1: Six themes and over 40 indicators are recommended by the CHSA committee for consider-ation in the Identifying Strategic Issues phase:1. Built Environment2. Healthy Living3. Healthy Eating4. Teen/Adult Health5. Vaccine-Preventable Disease6. Maternal and Child HealthRecommendation #2: The CHSA committee recommends that the Steering Committee review and consider thechallenges, opportunities, and suggestions listed in the table above during the remaining MAPP phases. These issuesare listed below:• Quality of life – update data gaps and create new data collection methods• Civic engagement – research and create new data collection methods• Indicators without data – research to address gaps in data and include prioritized indicators in next community survey• Indicators without benchmarks – research to address gaps in data• Teen health data – address data gap, explore oversampling for Oakland, and encourage schools to participate in the MiPHY survey• Health disparity and equity – discuss earlier in the process and consider information presented in results section during selecting strategic issues phase• Place Matters – research more information about this issue CHSA • August 2015 35

APPENDIX A: CORE INDICATOR CATEGORIES The CHSA data review and indicator selection, MAPP’s eleven broad-based core and extended data categories (see Appendix B) were used. The data categories measure health or related contributing factors that potentially effect community health status. Category One: Demographic Characteristics Definition of Category: Demographic characteristics include measures of total population; percent of total population by age group, gender, race and ethnicity; where these populations and subpopulations are located; and the rate of change in population density over time due to births, deaths and migration patterns. • Overall Demographic Information • Demographic Profile: Age and Sex • Demographic Profile: Race / Ethnic Distribution Category Two: Socioeconomic Characteristics Definition of Category: Socioeconomic characteristics include measures that have been shown to affect health status, such as income, education, and employment, and the proportion of the population represented by various levels of these variables. Socioeconomic Measure County/State • Employment/Unemployed • Percent Below Poverty Level • Median Household Income • Ratio of students graduating who entered 9th grade 3 years prior • Persons aged 25 and older with less than a high school education • Persons without health insurance • Single parent families • Special Populations 1. Migrant persons 2. Homeless persons 3. Non-English speaking36 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENTCategory Three: Health Resource AvailabilityDefinition of Category: This domain represents factors associated with health system capacity, which may includeboth the number of licensed and credentialed health personnel and the physical capacity of health facilities. Inaddition, the category of health resources includes measures of access, utilization, cost and quality of health careand prevention services. Service delivery patterns and roles of public and private sectors as payers and/or providersmay also be relevant.• Medicaid eligibles to participating physicians• Licensed dentists: rate total population• Licensed primary care physicians (general practice, family practice, internal, ob/gyn, and pediatrics): rate total population• Licensed hospital beds: total, acute, specialty beds: rate total population (and occupancy rate)• Visiting nurse services/in home support services: rate total population• Proportion of population without a regular source of primary care (including dental services)• Per capita health care spending for Medicare beneficiaries (the Medicare adjusted average per capita cost)• Local health department full-time equivalent employees (FTEs): number per total population• Total operating budget of local health department: dollars per total populationCategory Four: Quality of LifeDefinition of Category: Quality of Life (QOL) is a construct that “connotes an overall sense of well-being whenapplied to an individual” and a “supportive environment when applied to a community” (Moriarty, 1996). Somedimensions of QOL can be quantified using indicators that research has shown to be related to determinantsof health and community well-being. However, other valid dimensions of QOL include perceptions of communityresidents about aspects of their neighborhoods and communities that either enhance or diminish their quality of life.• Proportion of persons satisfied with the quality of life in the community• Proportion of adults satisfied with the health care system in the community• Proportion of parents in the PTA• Number of openings in child care facilities for low income families• Number of neighborhood crime watch areas• Civic organizations/association members per 1,000 population• Percent of registered voters who voteCategory Five: Behavioral Risk FactorsDefinition of Category: Risk factors in this category include behaviors which are believed to cause, or be contributingfactors of injuries, disease, and death during youth and adolescence and significant morbidity and mortality in CHSA • August 2015 37

APPENDIX A: CORE INDICATOR CATEGORIES (CONTINUED) later life. The indicators below correlate with information found in the Behavioral Risk Factor Surveillance System (BRFSS). For more information, go to http://www.cdc.gov/nccdphp/brfss/pdf/userguide.pdf. For each of the following, risk is examined by percent of total population by subgroups: age, gender, race, ethnicity, income, education: • Substance Use and Abuse 1. Tobacco use 2. Illegal drug use 3. Binge drinking • Lifestyle 1. Nutrition 2. Obesity 3. Exercise 4. Sedentary lifestyle • Protective Factors (safety) 1. Seat belt use 2. Child safety seat use 3. Bicycle helmet use 4. Condom use • Screening 1. Pap Smear 2. Mammography Category Six: Environmental Health Indicators Definition of Category: The physical environment directly impacts health and quality of life. Clean air and water, as well as safely prepared food, are essential to physical health. Exposure to environmental substances such as lead or hazardous waste increases risk for preventable disease. Unintentional home, workplace, or recreational injuries affect all age groups and may result in premature disability or mortality. • Air quality: number and type of U.S. Environmental Protection Agency air quality standards not met • Water quality: proportion of assessed rivers, lakes, and estuaries that support beneficial uses (e.g., fishing and swimming approved) • Indoor clean air: Percent of public facilities designated tobacco-free38 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENT• Workplace hazards: percent of OSHA violations• Food safety: foodborne disease: rate per total population• Lead exposure: percent of children under 5 years of age who are tested and have blood levels exceeding 10mcg/dL• Waterborne disease: rate per total population• Fluoridated water: percent total population with fluoridated water supplies• Rabies in animals: number of casesCategory Seven: Social and Mental HealthDefinition of Category: This category represents social and mental factors and conditions which directly or indirectlyinfluence overall health status and individual and community quality of life. Mental health conditions and overallpsychological well-being and safety may be influenced by substance abuse and violence within the home and withinthe community.• During the past 30 days, average number of days for which adults report that their mental health was not good• Number and rate of confirmed cases of child abuse and neglect among children• Homicide rate - age adjusted: total, white, non-white• Suicide rate - age adjusted: total, white, non-white; teen suicide• Domestic violence: rate per total population• Psychiatric admissions: rate per total population• Alcohol-related motor vehicle injuries/mortality: rate per total population• Drug-related mortality rateCategory Eight: Maternal and Child HealthDefinition of Category: One of the most significant areas for monitoring and comparison relates to the health of avulnerable population: infants and children. This category focuses on birth data and outcomes as well as mortalitydata for infants and children. Because maternal care is correlated with birth outcomes, measures of maternalaccess to, and/or utilization of, care is included. Births to teen mothers is a critical indicator of increased risk forboth mother and child.• Infant mortality (death within 1st year): total, white, non-white rate per 1000 live births• Entrance into prenatal care in 1st trimester: percent total, white, non-white per live births• Births to adolescents (ages 10-17) as a proportion of total live births• Adolescent pregnancy rate (ages 15-17)• Very low birthweight (less than 1,500 grams): percent total live births, white, non-white CHSA • August 2015 39

APPENDIX A: CORE INDICATOR CATEGORIES (CONTINUED) • Child mortality: rate per population age 1-14 / 100,000 • Neonatal mortality: total, white, non-white, rate per live births • Post Neonatal mortality: total, white, non-white rate per live births Category Nine: Death, Illness, and Injury Definition of Category: Health status in a community is measured in terms of mortality (rates of death within a population) and morbidity (rates of the incidence and prevalence of disease). Mortality may be represented by crude rates or age-adjusted rates (AAM), by degree of premature death (Years of Productive Life Lost or YPLL), and by cause (disease - cancer and non-cancer or injury - intentional, unintentional). Morbidity may be represented by age-adjusted (AA) incidence of cancer and chronic disease. • General health status (percent respondents reporting their health status as excellent, very good, good, fair, poor) • Average number of sick days within the past month • All causes: age-adjusted Mortality (AAM), total, by age, race, and gender • All cancers: AAM, total, white, non-white • Unintentional Injuries: total, by age, race, and gender • Years of Productive Life Lost (YPLL): number of YPLL under age 75 per population (total, white, non-white) • Breast cancer • Lung cancer • Cardiovascular disease • Motor vehicle crashes • Cervical cancer • Colorectal cancer • Chronic obstructive lung disease • Chronic liver disease and cirrhosis: AAM, total, white, non-white • Diabetes mellitus: AAM, total, white, non-white • Pneumonia/influenza: AAM, total, white, non-white • Stroke: AAM, total, white, non-white (CHSI Report) Category Ten: Communicable Disease Definition of Category: Measures within this category include diseases which are usually transmitted through person- to-person contact or shared use of contaminated instruments/materials. Many of these diseases can be prevented through a high level of vaccine coverage of vulnerable populations or through the use of protective measures such as condoms for the prevention of sexually-transmitted diseases.40 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENT• Proportion of 2-year old children who have received all age-appropriate vaccines, as recommended by the Advisory Committee on Immunization Practices• Proportion of adults aged 65 and older who have ever been immunized for pneumococcal pneumonia• Proportion of adults aged 65 and older who have been immunized in the past 12 months for influenza• Vaccine preventable: Percent of appropriately immunized children/population• Syphilis (primary and secondary) cases: reported incidence by age, race, gender• Gonorrhea cases: rate total population• Chlamydia: reported incidence• Tuberculosis: AAM, reported incidence by age, race, and gender and number of cases• AIDS: AAM, reported incidence by age, race, gender• Bacterial meningitis cases: reported incidence• Hepatitis A cases: reported incidence• Hepatitis B cases: reported incidence• Hepatitis C cases: reported incidenceCategory Eleven: Sentinel EventsDefinition of Category: Sentinel events are those cases of unnecessary disease, disability, or untimely death thatcould be avoided if appropriate and timely medical care or preventive services were provided. These includevaccine-preventable illness, late-stage cancer diagnosis, and unexpected syndromes or infections. Sentinel eventsmay alert the community to health system problems such as inadequate vaccine coverage, lack of primary careand/or screening, a bioterrorist event, or the introduction of globally-transmitted infections.• Vaccine-preventable disease 1. Measles: number and rate/total population 2. Mumps: number and rate/total population 3. Rubella: number and rate/total population 4. Pertussis: number and rate/total population 5. Tetanus: number and rate/total population• Other 1. Percent late stage diagnosis cancer – cervical 2. Percent late stage diagnosis cancer – breast 3. Number of deaths or age-adjusted death rate for work-related injuries 4. Unexpected syndromes due to unusual toxins or infectious agents, possibly related to a bioterrorist event (i.e., smallpox, anthrax) CHSA • August 2015 41

APPENDIX B: EXTENDED INDICATORS LISTS Category One: Demographic Characteristics None Category Two: Socioeconomic Characteristics • Per capita income • WIC eligibles: percent of total population • Medicaid eligibles: percent of total population • High school graduation rate • Percent of population with a college or higher level of education • Food stamp recipients • Percent of total population • Number of subsidized housing units per total number of households Category Three: Health Resource Availability • Medicaid physician availability: ratio • Medicaid dentist availability: ratio • Licensed doctors: rate total population • Licensed opticians/optometrists: rate total population • Licensed practical nurses: rate total population • Licensed advanced registered nurse practitioners: rate total population • Licensed registered nurses: rate total population • Nursing home beds: rate total population (and occupancy rate) • Adult living facility beds: total population • Percent of population provided primary care services by private providers • Percent of population provided primary care services by community and migrant health centers • Percent of population provided primary care services by other sources Category Four: Quality of Life • Proportion of residents planning to stay in the community / neighborhood for next five years • Proportion of youth involved in organized after-school recreational / educational activities • Number of child care facilities / preschool-age population42 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENT• Number of small/medium licensed businesses/population• Number of small locally owned businesses/population• Proportion of minority-owned businesses• Number of neighborhood/community-building get-togethers/year• Number of support resources identified by residents• Outreach to the physically, mentally, or psychologically challenged• Number of cultural events per year• Number of ethnic events per year• Number of inter-ethnic community groups and associations• Participation in developing a shared community vision• Number of grass roots groups active at neighborhood level• Number of advocacy groups active at community level• Civic participation hours/week (volunteer, faith-related, cultural, political)• Percent registered to voteCategory Five: Behavioral Risk FactorsNoneCategory Six: Environmental Health Indicators• Solid Waste Management: number of sanitary nuisance complaints• Solid Waste Management: percent of residences serviced by sanitary elimination program (garbage pickup, recycling)• Solid Waste Management: pounds of recycled solid waste per day per person• Compliance in tributary streams with water standards for dissolved oxygen• Salmonella cases: rate per total population• Shigella: rate per total population• Enteric cases: total cases per total population• Incidence of animal/vector-borne disease (e.g., Lyme, West Nile, encephalitis)• Contaminated wells: percent of total wells sampled• Septic tanks: rate per total population• Septic tanks: rate of failure• Sanitary nuisance complaints: rate per total population• Radon Detection: percent of homes tested for or remedied of excessive levels• Hazardous Waste Sites number: percent of population within exposure area• Percent of restaurants that failed inspection• Percent of pools that failed inspection• Number of houses built before 1950 (risk for lead-based paint exposure): number and proportion in community CHSA • August 2015 43

APPENDIX B: EXTENDED INDICATORS LISTS (CONTINUED) Category Seven: Social and Mental Health • Elderly abuse: rate per population > age 59 • Simple assaults: rate per total population • Aggravated assaults: rate per total population • Burglary: rate per total population • Illegal drug sales and possession: rate per total population • Forcible sex: rate per total population • Intentional injury: age-adjusted mortality • Alcohol-related mortality rate • Binge drinking: percent of adult population (Note: This indicator is also listed in the Category 7) • Treatment for mental disorder: percent of population • Crime rates: violent crimes, hate crimes, sexual assault Category Eight: Maternal and Child Health • Live birth rate • Fertility rates • 3rd trimester prenatal care: percent of total, white, non-white per live births • No prenatal care: percent of total, white, non-white live births • Prenatal care: no care, adequate care • Repeat births to teens • Family planning numbers as percent of target population • Low birthweight: percent of total, white, non-white live births • Perinatal conditions: AAM • Mortality due to birth defects: total, white, non-white rate population • EPSDT as percent of eligibles • WIC recipients as percent of eligibles • Teen and young adult tobacco smoking rates • C-section rate Category Nine: Death, Illness, and Injury • Morbidity (Incidence of newly diagnosed cases) 1. Breast cancer (total, white, non-white) 2. Cervical cancer (total, white, non-white) 3. Colorectal cancer 4. Lung and bronchus cancer 5. Prostate cancer 6. Melanoma 7. Oral cancer 8. Dental caries in school-aged children44 Energizing Connections for Healthier Oakland

COMMUNITY HEALTH STATUS ASSESSMENT• Hospitalizations (number and rate/total pop.) for the following: 1. Asthma 2. Cellulitis 3. Congestive heart failure 4. Diabetes 5. Gangrene 6. Influenza 7. Malignant hypertension 8. Perforated/bleeding ulcers 9. Pneumonia 10. Pyelonephritis 11. Ruptured appendixCategory Ten: Communicable Disease• Nosocomial infections• Group B streptococcusCategory Eleven: Sentinel Events• Congenital syphilis• Childhood TB• Drug-resistant TB• Residential fire deaths (number and rate)• Drug overdose deaths (number and rate)• Gun-related youth deaths• Maternal deaths CHSA • August 2015 45

APPENDIX C: BENCHMARK COMPARISON RESULTSWorse Than Benchmark About The Same as BenchmarkSeatbelt Use (Adults) - HP2020 Mammogram - MITobacco Use (Adults) - HP2020 Homicide - HP2020Suicide - HP2020 Infant Mortality - HP2020% Weight Gained While Pregnant Births in Teens - MI- Excessive - MI Neonatal Mortality - HP2020Syphilis (Male) - HP2020 Post-neonatal Mortality - HP2020Hepatitis A - OCHD No Prenatal Care - MIHepatitis C (Acute) - OCHD Low Birth Weight - HP2020Cardiovascular Disease - HP2020 Tuberculosis - OCHDImmunizations Kids - HP2020 AIDS - OCHDImmunizations Adults Pneumonia - HP2020 Bacterial Meningitis - OCHDPertussis - OCHD Rubella - OCHDPontiac - Total Infant Mortality Rate - MI Hepatitis B (Acute) - HP2020Southfield - Black Infant Mortality Rate - OCHD Measles - OCHDUse of Transportation - US Chronic Obstructive Lung DiseasePopulation Living in Food Deserts - MI & US (Mortality) - HP2020Low or No Healthy Food Access - MI & US Chronic Liver Disease (Mortality) - HP2020Fast Food Restaurant Rate - MI & US Stroke - HP2020Liquor Store Rates - US Grocery Store Rates - MI & US Infant Mortality: OC Total White - MI Better Than Benchmark% Smoke - MI Pap Test History - MI All Causes of Death AAM - MI All Cancers AAM - HP2020General Health Status - MI Child Abuse - MI Unintentional Injuries - HP2020 YPLL - HP2020Binge Drinking (Adults) - HP2020 Child Mortality - MI Colorectal Cancer (Mortality) - HP2020 Chronic Liver Disease (Mortality) -Physically Inactive (Adults) - HP2020 Adolescent Pregnancy Rate HP2020 (15 - 19 yr) - HP2020 Diabetes-Related Mortality - HP2020Obesity (Adults) - HP2020 Gonorrhea (10-year average) - OCHD Entrance into Prenatal Care (FirstFruit & Vegetable Consumption Trimester) - HP2020(Adults) - HP2020 Very Low Birth Weight - HP2020Recreation & Fitness Facility Access -MI & US Pregnant Women Healthy Weight - HP202046 Energizing Connections for Healthier Oakland