For this assignment you will collect data on two social determinants of health and two health outcomes for two counties and compare them to state and national data.

H S C I 6 3 0 7 – W E E K 4

TEXAS-MEXICO BORDER HEALTH INDICATORS

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HEALTH DISPARITIES L O W E R R I O G R A N D E V A L L E Y

SOCIAL DETERMINANTS OF HEALTH CONCEPTUAL FRAMEWORK

Source: World Health Organization. 2010. A Conceptual Framework for Action on the Social Determinants of Health.

Remember that health disparities are the result of several factors operating in complex sociologic, cultural, political, economic, and health care contexts.

HEALTH DISPARITIES INDICATORS

•Social Determinants of Health

•Health Behaviors

•Health Outcomes

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The following slides will review several social determinants of health, health behaviors and health outcomes for the Lower Rio Grande Valley along the Texas-Mexico border.

LOWER RIO GRANDE VALLEY

• Counties: Cameron, Hidalgo, Starr & Willacy

• Population: 1.3+ million • Ethnicity: 90% of

Hispanic or Latino origin

Source: U.S. Census Bureau, 2012-2016 American Community Survey 5-Year Estimates 5

STRUCTURE

• For each social determinant, you will get a preview of what research has shown followed by the corresponding measures for the four-county area compared to the nation and the state.

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HEALTH DETERMINANT S O C I O D E M O G R A P H I C S

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POVERTY

Research has shown that individuals who are poorer are more likely • To suffer from diseases • To be cognitively and physically impaired • To experience higher mortality rates

Poverty - the most deadly and prevalent of all diseases. Eugene O’Neill

Sources: Marmot MG, Kogevinas M, Elston MA. Social/economic status and disease. Annu Rev Public Health. 1987;8:111-35; Adler NE, Boyce WT, Chesney MA, Folkman S, Syme SL. Socioeconomic inequalities in health. No easy solution. JAMA. 1993;269(24):3140-5; Marmot M, Ryff CD, Bumpass LL, Shipley M, Marks NF. Social inequalities in health: Next questions and converging evidence. Soc Sci Med. 1997;44(6):901-10.

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PEOPLE LIVING IN POVERTY*

16% 18%

35% 35%

39% 38%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

*Percentage of people whose income in the past 12 months is below the poverty level Source: U.S. Census Bureau, 2010-2014 American Community Survey 5-Year Estimates 9

PEOPLE LIVING IN POVERTY*

16% 18%

35% 35%

39% 38%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

*Percentage of people whose income in the past 12 months is below the poverty level Source: U.S. Census Bureau, 2010-2014 American Community Survey 5-Year Estimates 10

PER CAPITA INCOME

$28,555 $26,513

$14,898 $14,525

$11,935 $11,693

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

Source: U.S. Census Bureau, 2010-2014 American Community Survey 5-Year Estimates 11

PER CAPITA INCOME

$28,555 $26,513

$14,898 $14,525

$11,935 $11,693

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

Source: U.S. Census Bureau, 2010-2014 American Community Survey 5-Year Estimates 12

EDUCATIONAL ATTAINMENT

• Individuals with less education relative to those with more education • are more likely to experience obesity, substance abuse, and

intentional and unintentional injury • live shorter lives

• Study published in 2015* • If every adult high school dropout in the 2010 population had a

GED or a regular diploma, 145,243 deaths could be avoided. • If everyone in the population got a bachelor's degree, the total

untimely deaths would be reduced by 554,525.

*Source: Krueger PM, Tran MK, Hummer RA, Chang VW. Mortality Attributable to Low Levels of Education in the United States. PLoS One. 2015 Jul 8;10(7):e0131809.

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HIGH SCHOOL GRADUATES*

86% 82%

64% 62%

47%

63%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

*Percentage of population who have a high school diploma/GED or Higher Source: U.S. Census Bureau, 2010-2014 American Community Survey 5-Year Estimates 14

HIGH SCHOOL GRADUATES*

86% 82%

64% 62%

47%

63%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

*Percentage of population who have a high school diploma/GED or Higher Source: U.S. Census Bureau, 2010-2014 American Community Survey 5-Year Estimates 15

HEALTH DETERMINANT H E A L T H C A R E ( A C C E S S & Q U A L I T Y )

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HEALTH CARE COVERAGE

• Uninsured young children relative to insured children • have lower immunization rates • are less likely to receive medical care for common

childhood conditions, such as sore throat, or for emergencies, such as a ruptured appendix

• are at greater risk of dying when hospitalized • Uninsured adults relative to insured adults

• are less likely to receive preventive services or screenings, such as mammograms or prostate screening  higher likelihood of preventable illness, missed diagnoses, and delays in treatment

• are less likely to receive care following a car accident and are at greater risk of death

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UNINSURED

10%

19%

30% 30% 28%

23%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

Under 65 years

Percent of population uninsured Source: U.S. Census Bureau, Small Area Health Insurance Estimates, 2016 18

UNINSURED

10%

19%

30% 30% 28%

23%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

Under 65 years

Percent of population uninsured Source: U.S. Census Bureau, Small Area Health Insurance Estimates, 2016 19

UNINSURED

10%

19%

30% 30% 28%

23%

12%

23%

39% 41% 40%

30%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

Under 65 years 18-64 years

Percent of population uninsured Source: U.S. Census Bureau, Small Area Health Insurance Estimates, 2016 20

PRIMARY CARE PHYSICIAN RATES*

76

60

46 46

18

32

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

* Primary care physicians per 100,000 population Source: Area Health Resources Files: Dept. of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, Area Health Resources Files (AHRF), 2015. 21

PRIMARY CARE PHYSICIAN RATES*

76

60

46 46

18

32

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

* Primary care physicians per 100,000 population Source: Area Health Resources Files: Dept. of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, Area Health Resources Files (AHRF), 2015. 22

DENTIST RATES*

60

51

26 26

11 9

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

*Dentists per 100,000 population Source: Area Health Resources Files: Dept. of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, Area Health Resources Files (AHRF), 2015. 23

DENTIST RATES*

60

51

26 26

11 9

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

*Dentists per 100,000 population Source: Area Health Resources Files: Dept. of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, Area Health Resources Files (AHRF), 2015. 24

PSYCHIATRIST RATES*

10

6

3

1 0 0

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

*Psychiatrists per 100,000 population Source: Area Health Resources Files: Dept. of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, Area Health Resources Files (AHRF), 2015. 25

PSYCHIATRIST RATES*

10

6

3

1 0 0

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

*Psychiatrists per 100,000 population Source: Area Health Resources Files: Dept. of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, Area Health Resources Files (AHRF), 2015. 26

SPEAK ENGLISH LESS THAN VERY WELL

9%

14%

30% 32%

51%

21%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

*Percentage of population 5 years and over who speak English “less than very well” Source: U.S. Census Bureau, 2010-2014 American Community Survey 5-Year Estimates 27

SPEAK ENGLISH LESS THAN VERY WELL

9%

14%

30% 32%

51%

21%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

*Percentage of population 5 years and over who speak English “less than very well” Source: U.S. Census Bureau, 2010-2014 American Community Survey 5-Year Estimates 28

MAMMOGRAPHY SCREENING* HAD A MAMMOGRAM IN PAST 2 YEARS

63%

58% 55%

58%

44% 48%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

* Female Medicare enrollees, age 67-69 Source; The Dartmouth Atlas of Health Care, 2014 29

MAMMOGRAPHY SCREENING* HAD A MAMMOGRAM IN PAST 2 YEARS

63%

58% 55%

58%

44% 48%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

* Female Medicare enrollees, age 67-69 Source; The Dartmouth Atlas of Health Care, 2014 30

HEALTH DETERMINANT P H Y S I C A L E N V I R O N M E N T

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SEVERE HOUSING PROBLEMS*

19% 18%

25%

28%

21% 19%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

*Percentage of households with at least one of four housing problems: incomplete kitchen facilities, incomplete plumbing facilities, more than 1.5 persons per room, and cost burden greater than 50%. Source: U.S. Department of Housing and Urban Development, 2010-2014 32

SEVERE HOUSING PROBLEMS*

19% 18%

25%

28%

21% 19%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

*Percentage of households with at least one of four housing problems: incomplete kitchen facilities, incomplete plumbing facilities, more than 1.5 persons per room, and cost burden greater than 50%. Source: U.S. Department of Housing and Urban Development, 2010-2014 33

HEALTH DETERMINANT H E A L T H B E H A V I O R S

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PREVALENCE OF MEETING PHYSICAL ACTIVITY GUIDELINES*

53% 50%

45% 43%

36%

42%

56% 54%

52% 48%

37%

43%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

Females Males

*150 minutes of moderate activity per week, 75 minutes of vigorous activity, or the equivalent combination of moderate and vigorous activity; 2011 data Source: Institute for Health Metrics and Evaluation (IHME), US County Profiles. Seattle, WA: IHME, 2015. 35

PREVALENCE OF MEETING PHYSICAL ACTIVITY GUIDELINES*

53% 50%

45% 43%

36%

42%

56% 54%

52% 48%

37%

43%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

Females Males

*150 minutes of moderate activity per week, 75 minutes of vigorous activity, or the equivalent combination of moderate and vigorous activity; 2011 data Source: Institute for Health Metrics and Evaluation (IHME), US County Profiles. Seattle, WA: IHME, 2015. 36

PREVALENCE OF BINGE DRINKING*

12% 11%

9% 10% 9% 10%

25% 25%

29% 29% 30%

34%

18% 18% 19% 19% 20%

22%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

Females Males Both

* Age-standardized prevalence of one or more binge drinking episodes in the past month; 2012 data Source: Institute for Health Metrics and Evaluation (IHME), US County Profiles. Seattle, WA: IHME, 2015. 37

PREVALENCE OF BINGE DRINKING*

12% 11%

9% 10% 9% 10%

25% 25%

29% 29% 30%

34%

18% 18% 19% 19% 20%

22%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

Females Males Both

* Age-standardized prevalence of one or more binge drinking episodes in the past month; 2012 data Source: Institute for Health Metrics and Evaluation (IHME), US County Profiles. Seattle, WA: IHME, 2015. 38

TEEN BIRTH RATES*

24

52

73 76

92

72

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

*Number of births per 1,000 females, ages 15-19 years Source for U.S.: Centers for Disease Control and Prevention, 2014 Source for Texas and counties: County Health Rankings, 2007-2013 39

TEEN BIRTH RATES*

24

52

73 76

92

72

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

*Number of births per 1,000 females, ages 15-19 years Source for U.S.: Centers for Disease Control and Prevention, 2014 Source for Texas and counties: County Health Rankings, 2007-2013 40

HEALTH OUTCOMES M O R B I D I T Y

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OBESITY PREVALENCE*

36% 39%

47% 49%

56%

51%

34% 36%

42% 44%

46% 44%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

Females Males

*2011 data for individuals with a Body Mass Index of 30 or more Source: Institute for Health Metrics and Evaluation (IHME), US County Profiles. Seattle, WA: IHME, 2015. 42

OBESITY PREVALENCE*

36% 39%

47% 49%

56%

51%

34% 36%

42% 44%

46% 44%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

Females Males

*2011 data for individuals with a Body Mass Index of 30 or more Source: Institute for Health Metrics and Evaluation (IHME), US County Profiles. Seattle, WA: IHME, 2015. 43

TOTAL DIABETES PREVALENCE* AGE-STANDARDIZED

13% 15%

21% 21%

26%

22%

16% 18%

24% 24%

27% 24%

14% 16%

22% 22%

26%

23%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

Females Males Both

*Proportion of adults ≥20 years of age who report a previous diabetes diagnosis and/or have high FPG/A1C (FPG ≥126 mg/dL and/or A1C ≥6.5%); total diabetes prevalence is equal to the sum of diagnosed and undiagnosed diabetes prevalence; 2012 data Source: Institute for Health Metrics and Evaluation (IHME), US County Profiles. Seattle, WA: IHME, 2015.

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TOTAL DIABETES PREVALENCE* AGE-STANDARDIZED

13% 15%

21% 21%

26%

22%

16% 18%

24% 24%

27% 24%

14% 16%

22% 22%

26%

23%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

Females Males Both

*Proportion of adults ≥20 years of age who report a previous diabetes diagnosis and/or have high FPG/A1C (FPG ≥126 mg/dL and/or A1C ≥6.5%); total diabetes prevalence is equal to the sum of diagnosed and undiagnosed diabetes prevalence; 2012 data Source: Institute for Health Metrics and Evaluation (IHME), US County Profiles. Seattle, WA: IHME, 2015.

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DIABETES CONTROL* AGE-STANDARDIZED

23% 23%

19% 19% 19% 19%

16% 16%

12% 12% 10% 11%

19% 19%

16% 15% 15% 15%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

Females Males Both

*Proportion of adults ≥20 years of age with a previous diabetes diagnosis and/or high FPG/A1C who currently do not have high FPG/A1C (FPG≥126 mg/dL and/or A1C ≥6.5% ); 2012 data Source: Institute for Health Metrics and Evaluation (IHME), US County Profiles. Seattle, WA: IHME, 2015. 46

DIABETES CONTROL* AGE-STANDARDIZED

23% 23%

19% 19% 19% 19%

16% 16%

12% 12% 10% 11%

19% 19%

16% 15% 15% 15%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

Females Males Both

*Proportion of adults ≥20 years of age with a previous diabetes diagnosis and/or high FPG/A1C who currently do not have high FPG/A1C (FPG≥126 mg/dL and/or A1C ≥6.5% ); 2012 data Source: Institute for Health Metrics and Evaluation (IHME), US County Profiles. Seattle, WA: IHME, 2015. 47

HEALTH OUTCOMES M O R T A L I T Y

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DEATH RATES DEATHS FROM MULTIPLE CAUSES PER 100,000 POPULATION

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• Given the poor social determinants of health that characterize the Rio Grande Valley community, how would you expect the death rates to be in the Valley relative to Texas and the nation? • Higher • Lower • About the same

DEATH RATES DEATHS FROM MULTIPLE CAUSES PER 100,000 POPULATION

824

682 634

495

607

858

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

Crude

Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2014 on CDC WONDER Online Database, released 2015. 50

Death rates in Valley counties are lower than those in the U.S. and Texas. Surprised?!

DEATH RATES DEATHS FROM MULTIPLE CAUSES PER 100,000 POPULATION

824

682 634

495

607

858 790

745

664 594

702

890

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY

Crude Age-Adjusted

Crude death rates don’t reveal an accurate picture. Younger populations, such as that of the Valley, will have lower death rates. Adjusting for age is important. The same pattern persists. Surprised?!

Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2014 on CDC WONDER Online Database, released 2015. 51

HISPANIC PARADOX

• Hispanic paradox refers to the phenomenon that most Hispanic groups are characterized by low socioeconomic status, but better than expected mortality outcomes (death rates).

• Possible explanations • Possible under-reporting of Hispanic deaths • “Salmon bias”: Just like salmon that returns to where it was born

to die, immigrants go back home in old age. This results in an underestimation of death numbers in the U.S.

• Protective effects of immigrant status • Supportive aspects of Hispanic culture

Source: Markides KS, Coreil J. 1986. The Health of Hispanics in the Southwestern United States: An Epidemiologic Paradox. Public Health Rep. 01(3):253-65.

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HEALTH OUTCOMES Q U A L I T Y O F L I F E

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FAIR OR POOR HEALTH PERCENT OF ADULTS WHO REPORT POOR OR FAIR HEALTH

10%

18%

30%

25%

30%

10%

18%

30%

27%

33%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY*

Crude Age-Adjusted

*Data is statistically unreliable for Willacy County Source: for US: Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) , 2012 data; for state and counties: CDC, NCHS. Health Indicators Warehouse. 2006-2012 BRFSS data.54

FAIR OR POOR HEALTH PERCENT OF ADULTS WHO REPORT POOR OR FAIR HEALTH

10%

18%

30%

25%

30%

10%

18%

30%

27%

33%

U.S. TEXAS CAMERON COUNTY

HIDALGO COUNTY

STARR COUNTY WILLACY COUNTY*

Crude Age-Adjusted

*Data is statistically unreliable for Willacy County Source: for US: Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) , 2012 data; for state and counties: CDC, NCHS. Health Indicators Warehouse. 2006-2012 BRFSS data.55

WATCH

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