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Defiance County Community Health Status Assessment 2018

Examining the Health of Defiance County

FOREWORD

Once again on behalf of the POWER Defiance County Coalition, I am pleased to present the 2018 Defiance County Community Health Assessment Report. This report is the fifth community health assessment conducted by various social service, business, and government organizations in Defiance County in an effort to collect data reporting the health and health behaviors of Defiance County residents. Data was collected for this assessment with the assistance of the Hospital Council of Northwest Ohio.

Monitoring the health of local residents to identify community health problems is an essential public health service. This health status assessment should be used as a guide for strategic planning and decision making. It can help our communities identify new health concerns, measure the impact of current community improvement efforts, and guide the judicious use of local resources. However, this is only one planning tool. A true plan of action for community improvement will require taking a closer look at these survey results; seeking additional information from community residents, service providers, and others; identifying populations at risk for specific health conditions, and choosing effective strategies that will truly improve the health of Defiance County residents when put into action.

This report would not have been possible without the help of members of the POWER Defiance County Coalition as well as the groups who contributed financially. Both are acknowledged on the following pages. It is vital that assessments such as this continue so that scarce resources are used in the most advantageous ways. All contributions whether financial or expertise is greatly appreciated.

Addressing the needs of the Defiance County community will take further collaborations and partnerships of many individuals and agencies. The work of public health is more a system than a single agency. Working together we can achieve a healthier Defiance County.

Sincerely,

Jamie Gerken Health Commissioner Defiance County General Health District

FOREWORD | 1

ACKNOWLEDGEMENTS

This report has been funded by:

Four County ADAMhs Board City of Defiance Community Memorial Hospital Defiance County Commissioners Defiance County General Health District Mercy Health Defiance ProMedica Defiance Regional Hospital United Way of Defiance County

This report has been commissioned by POWER Defiance County: Promoting Overall Wellness and Empower Residents:

Ayersville Local Schools City of Defiance Community Memorial Hospital Credit Adjustments Inc. Defiance Area Foundation Defiance Area YMCA Defiance City Schools Defiance County Commissioners Defiance County Drug Free Coalition Defiance County General Health District Defiance County Juvenile Court Defiance County Ohio State University Extension Office Defiance County Public Library System Defiance Development and Visitors Bureau Defiance 2100 Fairview School District Family and Children First Council Four County ADAMhs Board Hicksville Schools Hicksville Village Maumee Valley Guidance Center Mercy Health Defiance Ministerial Association Northeastern Local Schools Northwestern Ohio Community Action Commission ProMedica Defiance Regional Hospital Recovery Services of Northwest Ohio United Way of Defiance County

Contact Information:

Jamie Gerken Health Commissioner Defiance County General Health District 1300 E. Second St., Ste 100 Defiance, Ohio 43512 [email protected] (419)784-3818 ACKNOWLEDGEMENTS | 2

Project Management, Secondary Data, Data Collection, and Report Development Hospital Council of Northwest Ohio

Britney L. Ward, MPH Margaret Wielinski, MPH Director of Community Health Improvement Assistant Director of Community Health Improvement

Selena Coley, MPH Tessa Elliott, MPH Community Health Improvement Coordinator Community Health Improvement Coordinator

Emily A. Golias, MPH, CHES Emily Stearns, MPH, CHES Community Health Improvement Coordinator Community Health Improvement Coordinator

Alyssa Miller Carolynn McCartney Graduate Assistant Undergraduate Assistant

Erin Rauschenberg Emily Soles Graduate Assistant Graduate Assistant

Data Collection & Analysis

Joseph A. Dake, Ph.D., MPH Professor and Chair School of Population Health University of Toledo

Aaron J Diehr, PhD, CHES Consultant

To see Defiance County data compared to other counties, please visit the Hospital Council of Northwest Ohio’s Data Link website at:

http://www.hcno.org/community/data-indicator.html

The 2018 Defiance County Health Assessment is available on the following websites:

Defiance County General Health District http://defiancecohealth.org/defiance-county-public-health/

Hospital Council of Northwest Ohio http://www.hcno.org/community/reports.html

ACKNOWLEDGEMENTS | 3

TABLE OF CONTENTS

EXECUTIVE SUMMARY Pages 6-30 Primary Data Collection Methods Pages 6-8 2016 Ohio State Health Assessment (SHA) Page 9 Data Summary Pages 10-23 Trend Summary Pages 24-30

ADULT HEALTH CARE ACCESS Health Care Coverage Pages 31-33 Access and Utilization Pages 34-35 Preventive Medicine Pages 36-38 Women’s Health Pages 39-41 Men’s Health Pages 42-45 Oral Health Pages 46-47 ADULT HEALTH BEHAVIORS Health Status Perceptions Pages 48-49 Weight Status Pages 50-52 Tobacco Use Pages 53-56 Alcohol Consumption Pages 57-60 Drug Use Pages 61-66 Sexual Behavior Pages 67-70 Mental Health Pages 71-73

ADULT CHRONIC DISEASE Cardiovascular Health Pages 74-78 Cancer Pages 79-82 Asthma Pages 83-84 Diabetes Page 85 Quality of Life Pages 86-87

SOCIAL CONDITIONS Social Determinants of Health Pages 88-92 Environmental Conditions Page 93 Parenting Page 94

YOUTH HEALTH Weight Status Pages 95-98 Tobacco Use Pages 99-101 Alcohol Consumption Pages 102-105 Drug Use Pages 106-108 Sexual Behavior Pages 109-112 Mental Health Pages 113-117 Social Determinants of Health Pages 118-119 Violence Pages 120-122

CHILD HEALTH Health and Functional Status Pages 123-126 Health Care Access Pages 127-129 Early Childhood (0-5 Years) Pages 130-131 Middle Childhood (6-11 Years) Pages 132-133 Family and Community Characteristics Pages 134-137 Parent Health Page 138

TABLE OF CONTENTS | 4 APPENDICES APPENDIX I — Health Assessment Information Sources Pages 139-141 APPENDIX II — Acronyms and Terms Pages 142-143 APPENDIX III — Weighting Methods Pages 144-145 APPENDIX IV — School Participation Page 146 APPENDIX V — Demographic Profile Pages 147-148 APPENDIX VI — Demographics and Household Information Pages 149-156 APPENDIX VII — County Health Rankings Pages 157-159

TABLE OF CONTENTS | 5 EXECUTIVE SUMMARY

This executive summary provides an overview of health-related data for Defiance County adults (ages 19 and older), youth (ages 12 through 18), and children (ages 0 through 11) who participated in a county-wide health assessment survey from January through March 2018. The findings are based on self-administered surveys using a structured questionnaire. The questions were modeled after the survey instruments used by the Centers for Disease Control and Prevention for their national and state Behavioral Risk Factor Surveillance System (BRFSS), Youth Risk Behavior Surveillance System (YRBSS), and the National Survey of Children’s Health (NSCH) which was developed by the Child and Adolescent Health Measurement Initiative. The Hospital Council of Northwest Ohio (HCNO) collected the data, guided the health assessment process, and integrated sources of primary and secondary data into the final report.

Primary Data Collection Methods

DESIGN

This community health assessment was cross-sectional in nature and included a written survey of adults, adolescents, and parents within Defiance County. From the beginning, community leaders were actively engaged in the planning process and helped define the content, scope, and sequence of the study. Active engagement of community members throughout the planning process is regarded as an important step in completing a valid needs assessment.

INSTRUMENT DEVELOPMENT

Three survey instruments were designed and pilot tested for this study: one for adults, one for adolescents in grades 6 through 12, and one for parents of children ages 0 through 11. As a first step in the design process, health education researchers from the University of Toledo and staff members from HCNO met to discuss potential sources of valid and reliable survey items that would be appropriate for assessing the health status and health needs of adults, adolescents, and children. The investigators decided to derive the majority of the adult survey items from the BRFSS, the majority of the adolescent survey items from the YRBSS, and the majority of the survey items for the parents of children 0 through 11 from the NSCH. This decision was based on being able to compare local data with state and national data.

The project coordinator from the Hospital Council of Northwest Ohio conducted a series of meetings with POWER Defiance County. During these meetings, HCNO and the planning committee reviewed and discussed banks of potential survey questions from the BRFSS, YRBSS, and NSCH surveys. Based on input from POWER Defiance County, the project coordinator composed drafts of surveys containing 113 items for the adult survey, 76 items for the adolescent survey, and 83 items for the 0 through 11 survey. Health education researchers from the University of Toledo reviewed and approved the drafts.

SAMPLING | Adult Survey

The sampling frame for the adult survey consisted of adults ages 19 and over living in Defiance County. There were 28,852 persons ages 19 and over living in Defiance County. The investigators conducted a power analysis to determine what sample size was needed to ensure a 95% confidence level with a corresponding margin of error of 5% (i.e., we can be 95% sure that the “true” population responses are within a 5% margin of error of the survey findings). A sample size of at least 379 adults was needed to ensure this level of confidence. The random sample of mailing addresses of adults from Defiance County was obtained from Melissa Data Corporation in Rancho Santa Margarita, California.

SAMPLING | Adolescent Survey

The sampling frame for the adolescent survey consisted of youth in grades 6 through 12 in Defiance County public school districts. For more information on participating districts and schools, see Appendix IV. Using the U.S. Census Bureau data, it was determined that approximately 3,845 youth ages 12 through 18 years old lived in Defiance County. A sample size of 349 adolescents was needed to ensure a 95% confidence interval with a corresponding 5% margin of error. Students were randomly selected and surveyed in the schools. EXECUTIVE SUMMARY | 6

SAMPLING | Child Survey

The sampling frame for the child survey consisted of children ages 0 through11 residing in Defiance County. Using U.S. Census Bureau data, it was determined that 6,340 children ages 0 through 11 resided in Defiance County. The investigators conducted a power analysis to determine what sample size was needed to ensure a 95% confidence level with corresponding confidence interval of 5% (i.e., we can be 95% sure that the “true” population responses are within a 5% margin of error). The sample size required to generalize to children aged 0 through 11 was 362. The random sample of mailing addresses of parents from Defiance County was obtained from Melissa Data Corporation in Rancho Santa Margarita, California.

PROCEDURE | Adult Survey

Prior to mailing the survey to adults, the project team mailed an advance letter to 1,200 adults in Defiance County. This advance letter was personalized; printed on POWER Defiance County stationery; and signed by Jamie Gerken, Defiance County Health Commissioner. The letter introduced the county health assessment project and informed the readers that they may be randomly selected to receive the survey. The letter also explained that the respondents’ confidentiality would be protected and encouraged the readers to complete and return the survey promptly if they were selected.

Three weeks following the advance letter, a three-wave mailing procedure was implemented to maximize the survey return rate. The initial mailing included a personalized hand signed cover letter (on POWER Defiance County stationery) describing the purpose of the study, a questionnaire printed on white paper, a self-addressed stamped return envelope, and a $2 incentive. Approximately three weeks after the first mailing, a second wave mailing included another personalized cover letter encouraging the recipient to reply, another copy of the questionnaire on white paper, and another reply envelope. A third wave postcard was sent three weeks after the second wave mailing. Surveys returned as undeliverable were not replaced with another potential respondent.

The response rate for the mailing was 40% (n=430: CI=± 4.68). This return rate and sample size means that the responses in the health assessment should be representative of the entire county.

PROCEDURE | Adolescent Survey

The survey was approved by all participating superintendents. Schools and grades were randomly selected. To ensure that students in a particular grade had an equal chance of being selected, the research team used “general” school classes like English or Health to distribute surveys. Classrooms were chosen by the school principal. Passive permission slips were mailed home to parents of any student whose class was selected to participate. The response rate was 93% (n= 467: CI=± 4.25).

PROCEDURE | Child Survey

Prior to mailing the survey to parents of 0 through 11-year-olds, the project team mailed an advance letter to 2,400 parents in Defiance County. This advance letter was personalized; printed on POWER Defiance County stationery; and signed by Jamie Gerken, Defiance County Health Commissioner. The letter introduced the county health assessment project and informed the readers that they may be randomly selected to receive the survey. The letter also explained that the respondents’ confidentiality would be protected and encouraged the readers to complete and return the survey promptly if they were selected.

EXECUTIVE SUMMARY | 7

DATA ANALYSIS

Individual responses were anonymous. Only group data was available. All data was analyzed by health education researchers at the University of Toledo using SPSS 23.0. Crosstabs were used to calculate descriptive statistics for the data presented in this report. To be representative of Defiance County, the adult data collected was weighted by age, gender, race, and income using 2016 Census data. Multiple weightings were created based on this information to account for different types of analyses. For more information on how the weightings were created and applied, see Appendix III.

LIMITATIONS

As with all county assessments, it is important to consider the findings in light of all possible limitations. First, the Defiance County adult assessment had a high response rate. However, if any important differences existed between the respondents and the non-respondents regarding the questions asked, this would represent a threat to the external validity of the results (the generalizability of the results to the population of Defiance County). If there were little to no differences between respondents and non-respondents, then this would not be a limitation.

It is important to note that although several questions were asked using the same wording as the Centers for Disease Control and Prevention (CDC) questionnaires and the NSCH questionnaire, the adult and parent data collection method differed. The CDC adult data and NSCH child data were collected using a set of questions from the total question bank, and adults were asked the questions over the telephone rather than via mail survey. The youth CDC survey was administered in schools in a similar fashion as this county health assessment.

This survey asked parents questions regarding their young children. Should enough parents have felt compelled to respond in a socially desirable manner which is inconsistent with reality, this would represent a threat to the internal validity of the results.

Lastly, caution should be used when interpreting subgroup results, as the margin of error for any subgroup is higher than that of the overall survey.

Secondary Data Collection Methods

HCNO collected secondary data from multiple sites, including county-level data, whenever possible. HCNO utilized sites such as the Behavioral Risk Factor Surveillance System (BRFSS), numerous CDC sites, U.S. Census data, Healthy People 2020, among other national and local sources. All primary data collected in this report is from the 2018 Defiance County Health Assessment (CHA). All other data is cited accordingly.

EXECUTIVE SUMMARY | 8 2016 Ohio State Health Assessment (SHA)

The 2016 Ohio State Health Assessment (SHA) provides data needed to inform health improvement priorities and strategies in the state. This assessment includes over 140 metrics, organized into data profiles, as well as information gathered through five regional forums, a review of local health department and hospital assessments, and plans and key informant interviews.

Similar to the 2016 Ohio SHA, the 2018 Defiance County Community Health Assessment (CHA) examined a variety of metrics from various areas of health including, but not limited to, health behaviors, chronic disease, access to health care, and social determinants of health. Additionally, the CHA studied themes and perceptions from local public health stakeholders from a wide variety of sectors. Note: This symbol will be displayed in the trend summary when an indicator directly aligns with the 2016 Ohio SHA.

The interconnectedness of Ohio’s greatest health challenges, along with the overall consistency of health priorities identified in this assessment, indicates many opportunities for collaboration between a wide variety of partners at and between the state and local level, including physical and behavioral health organizations and sectors beyond health. It is our hope that this CHA will serve as a foundation for such collaboration.

To view the full 2016 Ohio State Health Assessment, please visit: http://www.odh.ohio.gov/- /media/ODH/ASSETS/Files/chss/ship/SHA_FullReport_08042016.pdf?la=en

FIGURE 1.1 | State Health Assessment (SHA) Sources of Information

OHIO STATE HEALTH ASSESSMENT | 9 Data Summary | Health Care Access

HEALTH CARE COVERAGE

In 2018, 12% of Defiance County adults were without health care coverage. The top reason adults gave for being without health care coverage was they could not afford to pay the insurance premiums (44%).

Uninsured Defiance County Adults 30%

21% 20%

13% 12% 12% 11% 11% 11% 10% 10% 9% 6% 3%

0% Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

ACCESS AND UTILIZATION

Sixty-six percent (66%) of Defiance County adults had visited a doctor for a routine checkup in the past year. Half (50%) of adults went outside of Defiance County for health care services in the past year. More than one-fourth (27%) of adults did not get prescriptions from their doctor filled in the past year.

Defiance County Adults Who Had a Routine Check-up in the Past Year 100%

82% 80% 77% 66% 69% 66% 61% 60% 59% 59% 60% 54% 47% 40%

20%

0% Total Females 30-64 Years Income <$25K Defiance 2008 Defiance 2015

Note for graphs: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

PREVENTIVE MEDICINE

Almost three-quarters (73%) of adults ages 65 and over had a pneumonia vaccination at some time in their life. Fifty-eight percent (58%) of adults had a flu vaccine in the past year.

DATA SUMMARY | 10 WOMEN’S HEALTH

Almost half (48%) of Defiance County women over the age of 40 reported having a mammogram in the past year. Thirty-nine percent (39%) of Defiance County women ages 19 and over had a clinical breast exam and 29% had a Pap smear to detect cancer of the cervix in the past year. Three percent (3%) of women survived a heart attack and 2% survived a stroke at some time in their life. Forty-one percent (41%) were obese, 34% had high blood pressure, 23% were diagnosed with high blood cholesterol, and 15% were identified as current smokers, known risk factors for cardiovascular diseases.

75% Defiance County Women's Health Exams Within the Past Year

57%

50% 47% 48% 41% 41% 43% 39% 40% 35% 35% 32% 31% 29% 31% 29% 25% 25% 17%

0% Total Under 40 Years 40 Years & Older Income <$25K Income >$25K Defiance 2015 Mammogram Breast Exam Pap Smear

MEN’S HEALTH

Forty-four percent (44%) of Defiance County males over the age of 50 had a Prostate-Specific Antigen (PSA) test in the past year. Almost two-fifths (39%) of men had been diagnosed with high blood pressure, 31% had high blood cholesterol, and 22% were identified as current smokers, which, along with obesity (38%), are known risk factors for cardiovascular diseases.

60% Defiance County Men's Health Exams Within the Past Year

44%

40%

24% 24% 21% 22% 20% 18% 17% 15%

10% 8% 5% 2%

0% Total Under 50 Years 50 Years & Older Income <$25K Income >$25K Defiance 2015

Prostate-Specific Antigen (PSA) Digital Rectal

Note for graphs: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

DATA SUMMARY | 11 ORAL HEALTH

Sixty-three percent (63%) of Defiance County adults visited a dentist or dental clinic in the past year. The top reasons adults gave for not visiting a dentist in the last year were cost (30%); no oral health problems or had not thought of it (23%); and fear, apprehension, nervousness, pain, and dislike going (15%).

100% Defiance County Adults Visiting a Dentist or Dental Clinic in the Past Year*

80% 66% 67% 65% 65% 63% 65% 63% 64% 61% 60% 57% 54%

40%

20%

0% Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

*Totals may not equal 100% as some respondents answered do not know.

Data Summary | Health Behaviors

HEALTH STATUS PERCEPTIONS

In 2018, almost half (46%) of Defiance County adults rated their health status as excellent or very good. Conversely, 15% of adults described their health as fair or poor, increasing to 24% of those with incomes less than $25,000.

Defiance County Adult Health Perceptions* 100% 7% 15% 15% 14% 16% 12% 13% 17% 12% 14% 22% 24% 80%

34% 37% 39% 37% 42% 34% 41% 43% 60% 40% 33%

40% 79%

53% 51% 46% 44% 49% 46% 49% 20% 41% 38% 43%

Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

Excellent/Very Good Good Fair/Poor

*Respondents were asked: “Would you say that in general your health is excellent, very good, good, fair or poor?” Note for graphs: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

DATA SUMMARY | 12 ADULT WEIGHT STATUS

Almost three-fourths (72%) of Defiance County adults were overweight or obese based on Body Mass Index (BMI). More than half (51%) of adults engaged in some type of physical activity or exercise for at least 30 minutes on 3 or more days per week.

Defiance County Adult BMI Classifications* 100%

30% 80% 38% 37% 35% 35% 40% 41% 39% 36% 45% 45%

60% 31% 32% 32% 40% 24% 40% 35% 39% 34% 40% 30% 20%

20% 39% 32% 30% 31% 27% 21% 23% 22% 25% 24% 27%

0% Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

Normal Overweight Obese

*Percentages may not equal 100% due to the exclusion of data for those who were classified as underweight

ADULT TOBACCO USE

In 2018, 19% of Defiance County adults were current smokers, and 21% were considered former smokers. Six percent (6%) of adults used e-cigarettes in the past year. Two-fifths (40%) of Defiance County adults believed that e-cigarette vapor was harmful to themselves.

Defiance County Adult Smoking Behaviors*

100%

80% 48% 54% 55% 50% 56% 60% 65% 60% 64% 72% 60% 86%

40% 30% 25% 29% 21% 26% 37% 15% 23% 21% 20% 13% 0% 22% 21% 21% 19% 15% 14% 20% 17% 18% 15% 8% 0% Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

Current smoker Former smoker Never smoked

*Respondents were asked: “Have you smoked at least 100 cigarettes in your entire life? If yes, do you now smoke cigarettes every day, some days or not at all?” Note for graphs: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

DATA SUMMARY | 13 ADULT ALCOHOL CONSUMPTION

In 2018, 56% of Defiance County adults had at least one alcoholic drink in the past month. One-quarter (25%) of adults reported they had five or more alcoholic drinks (for males) or four or more drinks (for females) on an occasion in the last month and would be considered binge drinkers. Twenty-eight percent (28%) of adults drove a vehicle or other equipment after consuming any alcoholic beverages.

Adults Average Number of Drinks Consumed Per Drinking Occasion 5 4.4 4.4 4.0 4 3.7 3.5 3.3

3 2.8 2.8 2.4 2.5 2.5

0 Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015 ADULT DRUG USE

In 2018, 4% of Defiance County adults had used marijuana during the past 6 months. Six percent (6%) of adults had used medication not prescribed for them or took more than prescribed to feel good or high and/or more active or alert during the past 6 months.

Defiance County Adult Marijuana Use in Past 6 Months 10%

5% 5% 5% 4% 4% 4% 4% 3% 2% 2%

0% 0% Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

Note for graphs: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey. ADULT SEXUAL BEHAVIOR

In 2018, 69% of Defiance County adults had sexual intercourse in the past year. One percent (1%) of adults had more than one partner. Seven percent (7%) Defiance County adults reported being forced to participate in sexual activity when they did not want to, increasing to 12% of females. Of those who were forced to have sexual activity, 27% reported it. DATA SUMMARY | 14 ADULT MENTAL HEALTH

In 2018, 2% of Defiance County adults considered attempting suicide. Eleven percent (11%) of adults felt so sad or hopeless almost every day for two weeks or more in a row that they stopped doing usual activities.

Defiance County Adults Feeling Sad or Hopeless for Two or More Weeks in a Row 30%

25% 23%

20% 16% 14% 15% 13% 12% 11% 11% 11% 10% 10% 8% 7% 5%

0% Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

Data Summary | Chronic Disease

CARDIOVASCULAR HEALTH

Five percent (5%) of adults had survived a heart attack and 3% had survived a stroke at some time in their life. Forty percent (40%) were obese, 36% had high blood pressure, 27% had high blood cholesterol, and 19% were current smokers, four known risk factors for heart disease and stroke.

Defiance County Adults with CVD Risk Factors 50%

40% 36%

27%

23% 25% 19% 13%

0% Obesity High Blood High Blood Sedentary Smoking Diabetes Pressure Cholesterol

DATA SUMMARY | 15 CANCER

In 2018, 9% of Defiance County adults had been diagnosed with cancer at some time in their life. The Ohio Department of Health (ODH) indicates that from 2014 to 2016, cancers caused 23% (274 of 1,181 total deaths) of all Defiance County resident deaths.

ASTHMA

In 2018, 14% of Defiance County adults had been diagnosed with asthma.

40% Defiance County Adults Diagnosed with Asthma

30% 27% 24% 20% 20% 14% 12% 11% 11% 9% 10% 9% 6% 3%

0% Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

DIABETES

In 2018, 13% of Defiance County adults had been diagnosed with diabetes. About two-fifths (38%) of adults with diabetes rated their health as fair or poor.

Defiance County Adults Diagnosed with Diabetes 40%

30% 28%

20% 16% 14% 15% 13% 12% 11% 12% 12% 9% 10%

0% 0% Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

Note for graphs: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

DATA SUMMARY | 16 QUALITY OF LIFE

One-fifth (20%) of adults had fallen in the past 6 months. Eight percent (8%) of adults were responsible for providing regular care or assistance to an elderly parent or loved one.

Defiance County Adults Limited in Some Way 80%

68%

61% 60% 49% 47% 46% 46% 43% 39% 40% 36% 37%

25%

20%

0% Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

Data Summary | Social Conditions

SOCIAL DETERMINANTS OF HEALTH

Seven percent (7%) of Defiance County adults were abused in the past year (including physical, emotional, financial, or verbal abuse). In the past 12 months, 7% of Defiance County adults had to choose between paying bills and buying food. Ten percent (10%) of adults experienced four or more Adverse Childhood Experiences (ACEs) in their lifetime.

ENVIRONMENTAL HEALTH

Nearly two-fifths (39%) of Defiance County adults had a private water source for drinking water. Seventy-four percent (74%) of adults preferred to get information from a television in a large-scale disaster or emergency.

PARENTING

In the past year, 52% of parents discussed dating and relationships with their 10- to 18-year-old child.

DATA SUMMARY | 17 Data Summary | Youth Health

YOUTH WEIGHT STATUS

In 2018, 19% of Defiance County youth were obese, according to Body Mass Index (BMI) by age. When asked how they would describe their weight, 32% of youth reported that they were slightly or very overweight. Nearly three- quarters (71%) of youth exercised for 60 minutes on 3 or more days per week.

Defiance County Youth BMI Classifications 3% 3% 3% 2% 5% 3% 9% 5% 4% 100%

80%

64% 64% 65% 65% 63% 64% 62% 60% 59% 68%

40%

14% 12% 14% 14% 14% 13% 16% 20% 18% 13%

21% 20% 19% 18% 19% 18% 14% 15% 18% 0% Total Male Female 13 or 14 to 16 17 & Older Defiance Defiance Defiance Younger 2008 2012 2015

Obese Overweight Normal Weight Underweight

YOUTH TOBACCO USE

In 2018, 6% of Defiance County youth were current smokers, increasing to 11% of those ages 17 and older. The average age of onset for smoking was 13.3 years old. Nine percent (9%) of youth used e-cigarettes in the past month.

20% Defiance County Youth Who Were Current Smokers

12% 11% 11% 10% 8% 8% 7% 6%

1% 0% Total Males Females 13 or 14 to 16 17 & Older Defiance Defiance Defiance Younger 2008 2012 2015

Note for graphs: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

DATA SUMMARY | 18 YOUTH ALCOHOL USE

Sixteen percent (16%) of Defiance County youth had at least one drink of alcohol in the past 30 days, increasing to 40% of those over the age of 17. Forty-four percent (44%) of youth who reported drinking in the past 30 days had at least one episode of binge drinking. Three percent (3%) of all youth drivers had driven a car in the past month after they had been drinking alcohol.

Defiance County Youth Who Had At least One Drink In Their Lifetime 100%

80%

61% 57% 60% 54% 50% 44% 41% 40% 41% 40%

23% 20%

0% Total Males Females 13 or 14 to 16 17 & Older Defiance Defiance Defiance Younger 2008 2012 2015

YOUTH DRUG USE

In 2018, 7% of Defiance County youth had used marijuana at least once in the past 30 days, increasing to 17% of those ages 17 and older. Five percent (5%) of youth used medications that were not prescribed for them or took more than prescribed to get high at some time in their life. More than two-fifths (42%) of youth indicated their parents as the biggest influencer for not doing alcohol, tobacco, or other drugs.

25% Defiance County Youth Marijuana Use in Past Month

20% 17%

15%

10% 9% 8% 8% 8% 7% 6% 6% 5% 2%

Total Males Females 13 or 14 to 16 17 & Older Defiance Defiance Defiance

Younger 2008 2012 2015

Note for graphs: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

DATA SUMMARY | 19 YOUTH SEXUAL BEHAVIOR

In 2018, one-fifth (20%) of Defiance County youth reported having had sexual intercourse. Sixteen percent (16%) of youth had participated in oral sex, and 3% had participated in anal sex. Seventeen percent (17%) of youth participated in sexting. Of those who were sexually active, 56% had multiple sexual partners.

75% Defiance County Youth Who Had Sexual Intercourse

48% 50%

28% 24% 23% 25% 22% 20% 18% 18%

0% 0% Total Males Females 13 or 14 to 16 17 & Older Defiance Defiance Defiance Younger 2008 2012 2015

YOUTH MENTAL HEALTH

Fourteen percent (14%) of Defiance County youth had seriously considered attempting suicide in the past year, and 7% attempted suicide in the past year, increasing to 10% of females. Two-fifths (40%) of Defiance County youth reported academic success caused them anxiety, stress, or depression. More than one-fourth (27%) of youth had three or more adverse childhood experiences (ACEs).

Defiance County Youth Who Had Seriously Considered Attempting Suicide in 30% the Past Year

20% 20% 17%

15% 15% 14% 14% 11% 11%

10% 8%

0% Total Males Females 13 or 14 to 16 17 & Older Defiance Defiance Defiance Younger 2008 2012 2015

Note for graphs: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

DATA SUMMARY | 20 YOUTH PERSONAL HEALTH AND SAFETY

Forty-three percent (43%) of Defiance County youth drivers had texted while driving in the past 30 days. Four percent (4%) of youth had played the choking game, also known as the pass-out game, space monkey, or dream game. Eighty-six percent (86%) of youth drivers reported always wearing a seatbelt when driving in a car.

YOUTH VIOLENCE

In the past month, 11% of Defiance County youth did not go to school on one or more days because they did not feel safe at school or on their way to or from school. Eight percent (8%) of youth had been hit, slapped, or physically hurt by an adult or caregiver in the past month. Thirty-six percent (36%) of youth had been bullied in the past year.

Defiance County Youth Who Did Not Go to School in the Past Month on One or 20% More Days Because They Felt Unsafe

15% 13% 12% 11% 10% 10% 8%

6% 5% 4% 4% 4%

0% Total Males Females 13 & 14 to 16 17 & Older Defiance Defiance Defiance Younger 2008 2012 2015

Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

DATA SUMMARY | 21 Data Summary | Child Health

HEALTH AND FUNCTIONAL STATUS

In 2018, 40% of children were classified as obese by Body Mass Index (BMI) calculations. More than four-fifths (82%) of Defiance County parents had taken their child to the dentist in the past year. Eleven percent (11%) of Defiance County parents reported their child had been diagnosed with asthma. Seven percent (7%) of parents reported their child had been diagnosed with ADD/ADHD.

20% Defiance County Children Diagnosed with Asthma 16% 15% 15% 12%

10% 9% 9% 6% 5%

0% Ages 0-5 Ages 6-11

Defiance County 2018 Ohio 2016 U.S. 2016

(Source: National Survey of Children’s Health & 2018 Defiance County Health Assessment)

HEALTH CARE ACCESS

In 2018, 5% of Defiance County parents reported their child did not currently have health insurance. Almost two- fifths (19%) of parents reported their child did not get all of the prescription medications they needed in the past year. Over three-fourths (78%) of parents had taken their child to the doctor for preventive care in the past year.

EARLY CHILDHOOD (0-5 YEARS OLD)

The following information was reported by parents of 0-5 year olds. Eighty-eight percent (88%) of mothers got prenatal care within the first three months during their last pregnancy. One-third (33%) of mothers received WIC services during their last pregnancy. Eighty-one percent (81%) of parents put their child to sleep on his/her back. Nineteen percent (19%) of mothers never breastfed their child.

MIDDLE CHILDHOOD (6-11 YEARS OLD)

The following information was reported by Defiance County parents of 6-11 year olds. In 2018, 62% of parents felt their child was always safe at school. More than two-fifths (45%) of parents reported their child was bullied at some time in the past year. Eighty-six percent (86%) of parents reported their child participated in extracurricular activities.

DATA SUMMARY | 22 FAMILY AND COMMUNITY CHARACTERISTICS

Thirteen percent (13%) of parents had at least one food insecurity issue in the past year. More than half (51%) of parents reported their child was always safe in their neighborhood or community. Nine percent (9%) of children experienced two or more Adverse Childhood Experiences (ACEs) in their lifetime.

100% Defiance County Families that Eat Together Everyday of the Week

80%

60%

43% 41% 43% 40%

20%

Defiance County 2018 Ohio 2016 U.S. 2016

PARENT HEALTH

In 2018, 67% of parents rated their health as excellent or very good, decreasing to 46% of parents with incomes less than $25,000. In the past year, 50% of parents missed work due to their child’s illnesses or injuries.

DATA SUMMARY | 23 ADULT TREND SUMMARY

Defiance Defiance Defiance Defiance Ohio U.S. Adult Variables County County County County 2016 2016 2008 2012 2015 2018 Health Status Rated health as excellent or very good 53% 49% 51% 46% 51% 52% Rated general health as fair or poor 13% 17% 12% 15% 18% 17% Average days that mental health not good in N/A N/A N/A 3.4 4.3¥ 3.8¥ past month Health Care Coverage, Access, and Utilization Uninsured 12% 10% 6% 12% 7% 10% Visited a doctor for a routine checkup in the 54% 59% 59% 66% 75% 71% past year Diabetes & Asthma Had been diagnosed with diabetes 12% 12% 9% 13% 11% 11% Had been diagnosed with asthma 3% 12% 9% 14% 10% 9% Cardiovascular Health Had angina or coronary heart disease 2% 2% 1% 6% 5% 5% Had a heart attack 4% 5% 5% 5% 5% 4% Had a stroke 2% 2% 3% 3% 4% 3% Had been diagnosed with high blood 18% 34% 32% 36% 34%* 31%* pressure Had been diagnosed with high blood 18% 24% 27% 27% 37%* 36%* cholesterol Had blood cholesterol checked within the 76% 75% 70% 78% 78%* 78%* past 5 years Weight Status Overweight 32% 39% 34% 32% 35% 35% Obese 35% 35% 36% 40% 32% 30% Alcohol Consumption Current drinker (drank alcohol at least once in 52% 53% 49% 56% 53% 54% the past month) Binge drinker (defined as consuming more than four [women] or five [men] alcoholic beverages 20% 20% 23% 25% 18% 17% on a single occasion in the past 30 days) Tobacco Use Current smoker (currently smoke some or all 21% 18% 15% 19% 23% 17% days) Former smoker (smoked 100 cigarettes in 29% 26% 21% 21% 24% 25% lifetime & now do not smoke) Tried to quit smoking (on at least one day in 65% 68% 53% 41% N/A N/A the past year) N/A - Not available *2015 BRFSS Data ¥2016 BRFSS as compiled by 2018 County Health Rankings Indicates alignment with the Ohio State Health Assessment

ADULT TREND SUMMARY | 24 Defiance Defiance Defiance Defiance Ohio U.S. Adult Variables County County County County 2016 2016 2008 2012 2015 2018 Drug Use Adults who used marijuana in the past 6 5% 4% 4% 4% N/A N/A months Adults who misused prescription medication 1% 7% 3% 6% N/A N/A in the past 6 months Sexual Behavior Had more than one sexual partner in past 7% 4% 4% 1% N/A N/A year Preventive Medicine Had a pneumonia vaccine (age 65 and older) N/A N/A 58% 73% 75% 73% Had a flu shot in the past year N/A N/A 76% 72% 57% 58% (ages 65 and older) Had a clinical breast exam in the past two 74% 66% 73% 56% N/A N/A years (age 40 and older) Had a mammogram in the past two years 69% 67% 80% 62% 74% 72% (age 40 and older) Had a Pap smear in the past three years 79% 74% 73% 57% 82%¥ 80%¥ Had a PSA test in within the past year 32% 28% 22% 24% N/A N/A Had a digital rectal exam within the past year 33% 22% 15% 10% N/A N/A Had a colonoscopy/sigmoidoscopy within the N/A 47% 51% 52% N/A N/A past 5 years (age 50 and over) Quality of Life Limited in some way because of physical, 25% 37% 39% 47% N/A N/A mental or emotional problem Mental Health Considered attempting suicide in the past 3% 2% 4% 2% N/A N/A year Two or more weeks in a row felt sad or 11% 13% 16% 11% N/A N/A hopeless Oral Health Adults who have visited the dentist in the 64% 65% 65% 63% 68% 66% past year N/A - Not available ¥BRFSS for both Ohio and U.S. reports for women ages 21-65 Indicates alignment with the Ohio State Health Assessment

ADULT TREND SUMMARY | 25 Youth Trend Summary

Defiance Defiance Defiance Defiance Defiance U.S. County County County County County Youth Variables 2017 2008 2012 2015 2018 2018 (9th-12th) (6th-12th) (6th-12th) (6th-12th) (6th-12th) (9th-12th) Weight Control Obese 14% 15% 18% 19% 20% 15% Overweight 18% 13% 16% 14% 13% 16% Described themselves as slightly or very 29% 29% 32% 32% 34% 32% overweight Tried to lose weight 45% 48% 46% 47% 49% 47% Exercised to lose weight (in the past 30 days) 50% 52% 49% 57% 58% N/A Ate less food, fewer calories, or foods lower in 27% 34% 33% 29% 33% N/A fat to lose weight (in the past 30 days) Went without eating for 24 hours or more (in the 4% 7% 7% 6% 6% 13%* past 30 days) Took diet pills, powders, or liquids without a 1% 2% 2% 1% 1% 5%* doctor’s advice (in the past 30 days) Vomited or took laxatives (in the past 30 2% 2% 2% 2% 1% 4%* days) Physically active at least 60 minutes per day on 31% 34% 31% 26% 31% 26% every day in past week Physically active at least 60 minutes per day on 53% 59% 55% 50% 55% 46% 5 or more days in past week Did not participate in at least 60 minutes of physical activity on any day in past 11% 8% 11% 13% 14% 15% week Watched 3 or more hours per day of television 36% 30% 23% 16% 15% 21% (on an average school day) Tobacco Use Ever tried cigarette smoking (even one or two 30% 31% 23% 15% 22% 29% puffs) Currently smoker (smoked on at least 1 day during 12% 11% 8% 6% 10% 9% the past 30 days) Smoked cigarettes on 20 or more days during 4% 2% 2% 1% 4% 3% the past month (of all youth) Smoked a whole cigarette for the first time 11% 7% 4% 4% 6% 10% before the age of 13 (of all youth) Alcohol Consumption Ever drank alcohol (at least one drink of alcohol 54% 57% 50% 41% 55% 60% on at least 1 day during their life) Current Drinker (at least one drink of alcohol on at 19% 24% 20% 16% 27% 30% least 1 day during the past 30 days) Binge drinker (drank 5 or more drinks within a couple of hours on at least 1 day during the past 30 10% 14% 10% 7% 13% 14% days) Drank for the first time before age 13 (of all 23% 14% 16% 13% 11% 16% youth) Rode with a driver who had been drinking alcohol (in a car or other vehicle on 1 or more 18% 13% 13% 13% 12% 17% occasion during the past 30 days) Drank and drove (of youth drivers) 5% 3% 2% 3% 6% 6% Obtained the alcohol they drank by someone 62% 39% 24% 44% 46% 44% giving it to them (of youth drinkers) N/A – Not Available *Comparative data for U.S. is 2013 Indicates alignment with the Ohio State Health Assessment

YOUTH TREND SUMMARY | 26 Defiance Defiance Defiance Defiance Defiance U.S. County County County County County 2017 Youth Variables 2008 2012 2015 2018 2018 (9th-12th) (6th-12th) (6th-12th) (6th-12th) (6th-12th) (9th-12th) Drug Use Used marijuana in the past month 8% 8% 9% 7% 12% 20% Ever used methamphetamines (in their lifetime) 3% 1% <1% <1% 0% 3% Ever used cocaine (in their lifetime) 2% 3% 2% 1% 2% 5% Ever used heroin (in their lifetime) 2% 1% 1% 1% 1% 2% Ever took steroids without a doctor's 2% 4% 2% 2% 2% 3% prescription (in their lifetime) Ever used inhalants (in their lifetime) 7% 8% 6% 4% 4% 6% Ever used ecstasy (also called MDMA/Molly in their N/A 2% 2% 1% 1% 4% lifetime) Misused prescription medication in their 7% 12% 9% 5% 7% N/A lifetime Sexual Behavior ¥ Ever had sexual intercourse 24% 28% 23% 20% 32% 40% Drank alcohol or used drugs before last sexual 17% 18% 18% 13% 14% 19% intercourse Used a condom (during last sexual intercourse) 66% 64% 61% 57% 62% 54% Used birth control pills (during last sexual 28% 32% 24% 37% 38% 21% intercourse) Did not use any method to prevent pregnancy 19% 13% 13% 10% 11% 14% during last sexual intercourse Had sexual intercourse with four or more 4% 5% 6% 5% 8% 10% persons (of all youth during their life) Had sexual intercourse before age 13 (of all 4% 3% 3% 2% 4% 3% youth) Mental Health Seriously considered attempting suicide (in the 11% 15% 15% 14% 14% 17% past 12 months) Attempted suicide (in the past 12 months) 7% 5% 5% 7% 6% 7% Felt sad or hopeless (almost every day for 2 or more weeks in a row so that they stopped doing 22% 25% 23% 28% 32% 32% some usual activities in the past 12 months) Social Determinants of Health Visited a dentist within the past year (for a check-up, exam, teeth cleaning, or other dental N/A 75% 76% 77% 80% 74%* work) Suffered a blow or jolt to their head while N/A N/A 18% 12% 12% N/A playing with a sports team in the past year Ever been told by a doctor or health professional 20% 20% 18% 14% 15% 23% they had asthma N/A – Not Available *Comparative YRBS data for U.S. is 2015 ¥Only students in grades 9th-12th were asked sexual health questions in 2012

YOUTH TREND SUMMARY | 27 Defiance Defiance Defiance Defiance Defiance U.S. County County County County County 2017 Youth Variables 2008 2012 2015 2018 2018 (9th-12th) (6th-12th) (6th-12th) (6th-12th) (6th-12th) (9th-12th) Violence Were in a physical fight (in the past 12 months) 27% 26% 26% 23% 21% 24% Carried a weapon (in the past 30 days) 11% 13% 13% 9% 11% 16% Did not go to school because they felt unsafe (at school or on their way to or from school in the past 4% 4% 4% 11% 10% 6% 30 days) Electronically bullied (in the past year) 8% 15% 13% 10% 8% 15% Bullied (in the past year) 51% 51% 49% 36% 31% N/A Were bullied on school property (during the past N/A 36% 31% 28% 24% 19% 12 months) Experienced physical dating violence (including being hit, slammed into something, or injured with 5% 6% 4% 4% 5% 8% an object or weapon on purpose by someone they were dating or going out with in the past 12 months) Ever physically forced to have sexual intercourse 3% 7% 4% 2% 2% N/A N/A – Not Available

YOUTH TREND SUMMARY | 28 CHILD TREND SUMMARY

Defiance Defiance Defiance Defiance Ohio U.S. Ohio U.S. County County County County 2016 2011 2016 2016 Child Comparisons 2015 2018 2015 2018 Ages Ages Ages Ages Ages Ages Ages Ages 0-5 0-5 6-11 6-11 0-5 0-5 6-11 6-11 Health and Functional Status Rated health as excellent or 94% 95% 94% 93% 92% 96% 91% 89% very good Dental care visit in the past year 53% 52% 54%* 59%* 89% 85% 95% 91% Diagnosed with asthma 2% 9% 9% 6% 9% 12% 16% 15% Diagnosed with diabetes 0% 0% N/A N/A <1% 0% N/A <1% Diagnosed with ADHD/ADD 2% 1% 2%** 3%** 8% 9% 13% 9% Diagnosed with behavioral or 0% 3% 3%** 5%** 3% 3% 13% 11% conduct problems Diagnosed with epilepsy 0% 3% N/A 1% <1% 2% N/A 1% Diagnosed with a head injury, 1% 1% N/A 1% 1% 1% N/A 2% brain injury, or concussion Diagnosed with depression 0% 0% N/A N/A 2% 1% N/A 2% Children who were born premature (more than 3 weeks N/A 9% 9% 11% N/A 7% 11% 12% before their due date) Child had one or more health N/A 9% 22% 22% N/A 10% 46% 42% conditions Health Care Access Had public insurance 27% 27% 28% 37% 19% 9% 33% 38% Been to doctor for preventive 86% 95% 91% 89% 64% 71% 83% 79% care in past year Received all the medical care 88% 92% N/A N/A 89% 86% N/A N/A they needed Had a personal doctor or nurse 80% 92% 75% 74% 74% 83% 77% 72% Child received treatment or counseling from a mental N/A 1% 1%* 3% N/A 8% 10% 10% health professional in the past year Early Childhood (Ages 0-5) Never breastfed their child 25% 19% 32% 21% N/A N/A N/A N/A Parent read to child every day 19% 35% 39% 38% N/A N/A N/A N/A Spent 4 or more hours watching 19% 9% 9% 9% N/A N/A N/A N/A TV Middle Childhood (Ages 6-11) Child participated in one or N/A N/A N/A N/A 85% 86% 82% 76% more activities Child did not miss any days of school because of illness or N/A N/A N/A N/A 27% 17% 26% 29% injury Did not engage in any physical N/A N/A N/A N/A 1% 1% 3% 5% activity during the past week Parent definitely agreed that N/A N/A N/A N/A 96% 96% 77% 79% their child was safe at school * Ages 1-5 **Ages 3-5 N/A – Not Available Indicates alignment with the Ohio State Health Assessment

CHILD TREND SUMMARY | 29 Defiance Defiance Defiance Defiance Ohio U.S. Ohio U.S. County County County County 2016 2011 2016 2016 Child Comparisons 2015 2018 2015 2018 Ages Ages Ages Ages Ages Ages Ages Ages 0-5 0-5 6-11 6-11 0-5 0-5 6-11 6-11 Family and Community Characteristics Family ate a meal together 50% 49% 51% 53% 40% 40% 43% 45% every day of the week Child experienced two or more ACEs N/A 7% 18% 12% N/A 10% 29% 23% Child never attends religious 5% 36% N/A N/A 12% 25% 22%* 18%* services Neighborhood is usually or 96% 91% 88%* 86%* 95% 91% 86%* 86%* always safe Parent Health Mother’s mental or emotional 1% 2% 5% 5% 5% 6% 9% 8% health is fair/poor Father’s mental or emotional 11% 2% 5% 3% 2% 2% 6% 3% health is fair/poor *2011/2012 NSCH Data N/A – Not Available Indicates alignment with the Ohio State Health Assessment

CHILD TREND SUMMARY | 30 Health Care Access: Health Care Coverage

Key Findings

In 2018, 12% of Defiance County adults were without health care coverage. The top reason adults gave for being without health care coverage was that they could not afford to pay the insurance premiums (44%).

General Health Coverage

• In 2018, 88% of Defiance County adults had health care coverage.

• In the past year, 12% of adults were uninsured. The 2016 BRFSS reported uninsured prevalence rates of 7% for Ohio and 10% for the U.S.

• Almost one-fifth (19%) of adults with children did not have health care coverage, compared to 5% of those who did not have children living in their household.

• The following types of health care coverage were used: employer (53%); Medicare (16%); someone else’s employer (9%); Medicaid or medical assistance (8%); multiple, including private sources (6%); self-paid plan (4%); military or VA (2%); multiple, including government sources (1%); and Health Insurance Marketplace (1%).

12% of Defiance County adults were uninsured.

• Defiance County adult health care coverage included the following: medical (97%), prescription coverage (94%), immunizations (83%), preventive health (80%), outpatient therapy (70%), dental (69%), vision/eyeglasses (69%), mental health (58%), durable medical equipment (40%), alcohol and drug treatment (32%), home care (25%), skilled nursing/assisted living (25%), hospice (22%), and transportation (15%).

• Defiance County adults had the following issues regarding their health care coverage: cost (30%), opted out of certain coverage because they could not afford it (8%), service not deemed medically necessary (4%), working with their insurance company (3%), could not understand their insurance plan (3%), service was no longer covered (2%), limited visits (2%), opted out of certain coverage because they did not need it (2%), provider was no longer covered (1%), and pre-existing conditions (1%).

• The top reasons uninsured adults gave for being without health care coverage were because they: — They could not afford to pay the premiums (44%) — They lost their job or changed employers (42%) — They became ineligible (15%)

Note: Percentages do not equal 100% because respondents could select more than one reason

Defiance Defiance Defiance Defiance Ohio U.S. Adult Comparisons County County County County 2016 2016 2008 2012 2015 2018

Uninsured 12% 10% 6% 12% 7% 10%

ADULT HEALTH CARE COVERAGE | 31

The following graph shows the percentage of Defiance County adults who were uninsured. Examples of how to interpret the information in the graph include: 12% of all adults were uninsured, including 9% of those with incomes less than $25,000 and 13% of females. The pie chart shows sources of Defiance County adults’ health care coverage.

Uninsured Defiance County Adults 30%

21% 20%

13% 12% 12% 11% 11% 11% 10% 10% 9% 6% 3%

0% Total Males Females Under 30 30-64 65 & Income Income Defiance Defiance Defiance Years Over <$25K >$25K 2008 2012 2015

Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

9% of Defiance County adults with incomes less than $25,000 were uninsured.

Source of Health Coverage for Defiance County Adults

Medicare

16% Medicaid 8%

Self-purchased Employer 4% 53%

Someone else's

employer 9%

Military 2%

Health Insurance Multiple- Multiple-private Marketplace governmenal sources 1% sources 6% 1% ADULT HEALTH CARE COVERAGE | 32

The following chart shows what is included in Defiance County adults’ insurance coverage.

Don’t Health Coverage Includes: Yes No Know

Medical 97% <1% 2%

Prescription Coverage 94% 4% 2%

Immunizations 83% 4% 13%

Preventive Health 80% 3% 17%

Outpatient Therapy 70% 3% 27%

Dental 69% 28% 3%

Vision/Eyeglasses 69% 26% 5%

Mental Health 58% 3% 39%

Durable Medical Equipment 40% 5% 55%

Alcohol and Drug Treatment 32% 6% 62%

Home Care 25% 10% 65%

Skilled Nursing/Assisted Living 25% 8% 67%

Hospice 22% 10% 68%

Transportation 14% 22% 64%

Healthy People 2020 Access to Health Services (AHS)

Healthy Defiance Ohio U.S. People Objective County 2016 2016* 2020 2018 Target

100% age 20-24 90% age 18-24 85% age 18-24 AHS-1.1: Persons 79% age 25-34 89% age 25-34 84% age 25-34 under age of 65 94% age 35-44 91% age 35-44 87% age 35-44 100% years with health 81% age 45-54 94% age 45-54 90% age 45-54 care insurance 92% age 55-64 94% age 55-64 93% age 55-64

*U.S. baseline is age-adjusted to the 2000 population standard Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey. (Sources: Healthy People 2020 Objectives, 2016 BRFSS, 2018 Defiance County Health Assessment)

ADULT HEALTH CARE COVERAGE | 33

Health Care Access: Access and Utilization

Key Findings

Health Care Access and Utilization

• Sixty-six percent (66%) of Defiance County adults visited a doctor for a routine checkup in the past year, increasing to 82% of those over the age of 65. The 2016 BRFSS reported prevalence rates of 75% for Ohio and 71% for the U.S.

• Adults with health care coverage were more likely to have visited a doctor for a routine checkup in the past year (66%), compared to 58% of those without health care coverage.

• Adults visited the following places for health care services or advice: doctor’s office (55%); multiple places, including a doctor’s office (13%); urgent care center (12%); internet (6%); a public health center or community health center (3%); alternative therapies (2%); chiropractor (2%); multiple places, not including a doctor’s office (1%); Department of Veteran’s Affairs (VA) (1%); hospital outpatient department (<1%); and in-store health clinic (<1%). One percent (1%) of adults indicated they had no usual place for health care services.

• Defiance County adults who did not receive medical care in the past 12 months reported the following reasons for not doing so: no need to go (50%), cost/no insurance (31%), office was not open when they could get there (3%), can access medical records online (2%), distance (2%), inconvenient appointment times (2%), too long of a wait for an appointment (1%), discrimination (1%), too long of a wait in waiting room (1%), and other problems that prevented them from getting medical care (10%).

• Defiance County adults preferred to access information about their health or health care services from the following: doctor (74%); internet searches (29%); family member or friend (28%); medical portal (10%); newspaper articles or radio/television news stories (7%); advertisings or mailings from hospitals, clinics, or doctor’s offices (6%); text messages (4%); social networks (3%); and other (4%).

• Two-thirds (66%) of adults indicated they had a usual source of medical care. Reasons for not having a usual source of medical care included the following: had not needed a doctor (11%), no insurance/cannot afford (8%), had two or more usual places (5%), previous doctor unavailable/moved (5%), no place is available/close enough (1%), did not know where to go (1%), do not like/trust/believe in doctors (1%), and other reasons (3%).

• Half (50%) of adults went outside of Defiance County for the following health care services in the past year: specialty care (42%), dental services (30%), primary care (25%), orthopedic care (11%), cardiac care (8%), obstetrics/gynecology (7%), mental health care/counseling services (6%), female health services (6%), pediatric care (6%), cancer care (4%), pediatric therapies (1%), and other services (16%).

• Forty-four percent (44%) of adults had used the emergency room for health care. Adults who used the emergency room for health care reported the following reasons: serious illness/injury (78%), could not get in to see primary care physician because of time a day/too long of a wait (17%), their doctor told them to go there (11%), do not have a primary care physician (7%), and what they have always done/what they are used to (1%).

• More than one-fourth (27%) of adults did not get prescriptions from their doctor filled in the past year. Those who did not get their prescriptions filled gave the following reasons: no prescriptions to be filled (51%), too expensive (24%), they did not think they needed it (11%), they stretched their current prescription by taking less than prescribed (10%), no insurance (7%), fear of addiction (4%), side effects (3%), there was no generic equivalent (2%), and they were taking too many medications (1%).

ADULT ACCESS AND UTLIZATION| 34

• Defiance County adults had not gotten any of the following recommended major care or preventive care due to cost: medications (11%), lab testing (11%), colonoscopy (9%), weight loss program (6%), mammogram (5%), mental health services (5%), surgery (5%), Prostate-Specific Antigen (PSA) test (4%), Pap smear (4%), immunizations (3%), smoking cessation (2%), family planning services (2%), and alcohol/drug treatment (1%).

• Defiance County adults had the following problems when they needed health care in the past year: could not get appointments when they wanted them (8%), did not have enough money to pay for health care or insurance (7%), too busy to get the health care they needed (7%), did not have insurance (6%), had to change doctors because of their health care plan (4%), health care plan did not allow them to see doctors in Defiance County (3%), could not find a doctor to take them as a patient (3%), could not find a doctor they were comfortable with (2%), did not have transportation (2%), too embarrassed to seek help (1%), did not have child care (1%), and other problems that prevented them from getting health care (1%).

• Adults traveled the following number of miles to get to the place they usually go for health care: fewer than 20 miles (86%), 20 to 40 miles (11%), 41 to 60 miles (1%), and more than 60 miles (2%).

Availability of Services

• Defiance County adults reported they had looked for the following programs: depression, anxiety or mental health (11%); weight problems (8%); eldercare (3%); disability (3%); alcohol abuse (3%); family planning (3%); fall prevention/balance (3%); marital or family problems (2%); detoxification for opiates/heroin (1%); drug abuse (1%); end-of-life/Hospice care (1%); and tobacco cessation (1%).

Defiance Defiance Defiance Defiance Ohio U.S. Adult Comparisons County County County County 2016 2016 2008 2012 2015 2018 Visited a doctor for a routine 54% 59% 59% 66% 75% 71% checkup in the past year

The following graph shows the percentage of Defiance County adults who had a routine check-up in the past year. Examples of how to interpret the information on the first graph include: 66% of all Defiance County adults have had a routine check-up in the past year, including 61% of all Defiance County males and 82% of those 65 years and older.

Defiance County Adults Who Had a Routine Check-up in the Past Year

100%

82% 80% 77%

66% 69% 66% 61% 60% 59% 59% 60% 54% 47% 40%

20%

0% Total Males Females Under 30 30-64 65 & Income Income Defiance Defiance Defiance

Years Over <$25K $25K Plus 2008 2012 2015

Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

ADULT ACCESS AND UTLIZATION| 35

Health Care Access: Preventive Medicine

Key Findings

Almost three-quarters (73%) of adults ages 65 and over had a pneumonia vaccination at some time in their life. Fifty-eight percent (58%) of adults had a flu vaccine in the past year.

Preventive Medicine

• Fifty-eight percent (58%) of Defiance County adults had a flu vaccine during the past 12 months, increasing to 72% of Defiance County adults ages 65 and over. The 2016 BRFSS reported that 57% of Ohio and 58% of U.S. adults ages 65 and over had a flu vaccine in the past year.

• Nearly half (47%) of adults have had a pneumonia vaccine in their life, increasing to 73% of those ages 65 and over. The 2016 BRFSS reported that 75% of Ohio and 73% of U.S. adults ages 65 and over had a pneumonia vaccine in their life.

• Defiance County adults have had the following vaccines: MMR in their lifetime (71%), tetanus booster (including Tdap) in the past 10 years (63%), chicken pox in their lifetime (56%), Zoster (shingles) vaccine in their lifetime (35%), pertussis vaccine in the past 10 years (18%), and human papillomavirus (HPV) vaccine in their lifetime (7%).

• Defiance County adults indicated a doctor or health professional talked to them about following topics: immunizations (42%); family history (41%); weight control (diet, physical activity) (34%); safe use of prescription medication (25%); depression, anxiety or emotional problems (21%); tobacco use (16%); safe use of opiate- based pain medication (11%); PSA test (11%); sexually transmitted diseases (STDs) (8%); alcohol use (7%); family planning (7%); self-testicular exams (7%); domestic violence (4%); illicit drug abuse (3%); and injury prevention such as safety belt use, helmet use, or smoke detectors (1%).

Preventive Health Screenings and Exams

• More than half (52%) of adults ages 50 and over had a colonoscopy or sigmoidoscopy in the past five years.

• In the past year, 48% of Defiance County women ages 40 and over had a mammogram.

• Forty-four percent (44%) of men ages 50 and over had a PSA test in the past year.

• See the Women and Men’s Health Sections for further prostate, mammogram, clinical breast exam, and Pap smear screening test information for Defiance County adults.

Defiance Defiance Defiance Defiance Ohio U.S. Adult Comparisons County County County County 2016 2016 2008 2012 2015 2018 Had a pneumonia vaccination N/A N/A 58% 73% 75% 73% (age 65 and over) Had a flu vaccine in the past year N/A N/A 76% 72% 57% 58% (age 65 and over) Had a colonoscopy/sigmoidoscopy within the past 5 years (age 50 and N/A 47% 51% 52% N/A N/A over) N/A – Not Available

ADULT PREVENTIVE MEDICINE | 36

Healthy People 2020 Immunization and Infectious Diseases (IID)

Defiance Healthy Ohio U.S. Objective County People 2020 2016 2016 2018 Target

IID-13.1: Increase the percentage of

non-institutionalized high-risk adults aged 65 years and older who 73% 75% 73% 90% are vaccinated against pneumococcal disease Note: U.S. baseline is age-adjusted to the 2000 population standard (Sources: Healthy People 2020 Objectives, 2016 BRFSS, 2018 Defiance County Health Assessment)

Defiance County Adults Having Discussed Health Care Topics With Their Health Care Professional in the Past 12 Months Total Total Health Care Topics 2015 2018 Immunizations 23% 42% Family History 17% 41% Weight Control 28% 34% Safe Use of Prescription Medication N/A 25% Depression, Anxiety, or Emotional Problems 15% 21% Tobacco Use N/A 16% PSA test N/A 11% Safe Use of Opiate-Based Pain Medication N/A 11% Sexually Transmitted Disease (STDs) N/A 8% Alcohol Use N/A 7% Self-Testicular Exams N/A 7% Family Planning N/A 7% Domestic Violence 1% 4% Illicit Drug Abuse 1% 3% Injury Prevention Such as Safety Belt Use & Helmet Use 4% 1% N/A – Not Available

ADULT PREVENTIVE MEDICINE | 37

(Source: Centers for Disease Control and Prevention, Recommended Immunizations for Adults, 2018)

ADULT PREVENTIVE MEDICINE | 38

Health Care Access: Women’s Health

Key Findings Defiance County Female Almost half (48%) of Defiance County women over the age Leading Causes of Death, 2014 – 2016 of 40 reported having a mammogram in the past year. Total Female Deaths: 610 Thirty-nine percent (39%) of Defiance County women ages 19 and over had a clinical breast exam and 29% had a Pap 1. Cancers (23% of all deaths) smear to detect cancer of the cervix in the past year. Three 2. Heart Diseases (21%) percent (3%) of women survived a heart attack and 2% 3. Chronic Lower Respiratory Diseases (9%) survived a stroke at some time in their life. Forty-one 4. Alzheimer’s Disease (6%) percent (41%) were obese, 34% had high blood pressure, 5. Stroke (5%)

23% were diagnosed with high blood cholesterol, and 15% (Source: Ohio Public Health Data Warehouse, 2014-2016) were identified as current smokers, known risk factors for cardiovascular diseases.

Ohio Female Women’s Health Screenings Leading Causes of Death, 2014 – 2016

Total Female Deaths: 176,669 • In 2018, 61% of women had a mammogram at some time, and more than one-third (35%) had this screening 1. Heart Diseases (22% of all deaths) in the past year. 2. Cancers (21%) 3. Chronic Lower Respiratory Diseases (6%) • Almost half (48%) of women ages 40 and over had a 4. Stroke (6%) mammogram in the past year, and 62% had one in the 5. Alzheimer’s disease (5%)

past two years. The 2016 BRFSS reported that 74% of (Source: Ohio Public Health Data Warehouse, 2014-2016) Ohio women 40 and over and 72% in the U.S., had a mammogram in the past two years.

• Eighty-eight percent (88%) of Defiance County women had a clinical breast exam at some time in their life, and 39% had one within the past year. Fifty-six percent (56%) of women ages 40 and over had a clinical breast exam in the past two years.

• Defiance County women completed an average of 6.3 self-breast exams in the past year.

• Ninety-three percent (93%) of Defiance County women had a Pap smear at some point in their life, and 29% reported having had the exam in the past year. Fifty-seven percent (57%) of women had a Pap smear in the past three years. The 2016 BRFSS indicated that 82% of Ohio and 80% of U.S. women had a Pap smear in the past three years.

Women’s Health Concerns

• Women used the following as their usual source of services for female health concerns: general or family physician (45%), private gynecologist (19%), nurse practitioner/physician assistant (10%), family planning clinic (5%), health department clinic (3%), community health center (1%), midwife (1%), and some other kind of place (1%). Fourteen percent (14%) indicated they did not have a usual source of services for female health concerns.

• Major risk factors for cardiovascular disease include smoking, obesity, high blood cholesterol, high blood pressure, physical inactivity, and diabetes. In Defiance County, the 2018 health assessment identified that:  66% of women were overweight or obese (2016 BRFSS reports 62% for Ohio and 59% for the U.S.)  34% were diagnosed with high blood pressure (2015 BRFSS reports 31% for Ohio and 30% for the U.S.) — 23% were diagnosed with high blood cholesterol (2015 BRFSS reports 36% for Ohio and 35% for U.S.) — 15% of all women were current smokers (2016 BRFSS reports 21% for Ohio and 14% for U.S.) — 12%% had been diagnosed with diabetes (2016 BRFSS reports 11% for Ohio and 11% for U.S.)

WOMEN’S HEALTH | 39

• In 2018, 3% of women had survived a heart attack and 2% had survived a stroke at some time in their life.

• From 2014 to 2016, major cardiovascular diseases (heart disease and stroke) accounted for 26% of all female deaths in Defiance County (Source: Ohio Public Health Data Warehouse, 2014-2016).

The following graph shows the percentage of Defiance County females who had various health exams in the past year. Examples of how to interpret the information shown on the graph include: 35% of females had a mammogram within the past year, 39% had a clinical breast exam, and 29% had a Pap smear.

75% Defiance County Women's Health Exams Within the Past Year

57%

50% 47% 48% 41% 41% 43% 39% 40% 35% 35% 32% 31% 29% 31% 29% 25% 25% 17%

6% 0% Total Under 40 40 & Older Income <$25K Income >$25K Defiance 2015

Mammogram Breast Exam Pap Smear

Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

Defiance Defiance Defiance Defiance Ohio U.S. Adult Comparisons County County County County 2016 2015 2008 2012 2015 2018 Had a clinical breast exam in the past two 74% 66% 73% 56% N/A N/A years (age 40 and over) Had a mammogram in the past two years 69% 67% 80% 62% 74% 72% (age 40 and over) Had a Pap smear in the past three years 79% 74% 73% 57% 82%* 80%*

N/A – Not Available *Ohio and U.S. BRFSS reports women ages 21-65

WOMEN’S HEALTH | 40

The following graph shows the Defiance County and Ohio age-adjusted cancer mortality rates per 100,000 population for women with comparison to Healthy People 2020 objectives. The graph shows:

• From 2014 to 2016, the Defiance County age-adjusted mortality rate for breast cancer was lower than both the Ohio rate and Healthy People 2020 target objective.

Defiance County Female Age-Adjusted Cancer Mortality Rates, 2014-2016

50 45.5 44.6 39.5 40

30 24.3 22.2 20.7 20 16.8 14.5 13.2 10

population 100,000 per Rate 0 Lung Cancer Colon/Rectum Cancer Breast Cancer

Defiance County 2014-2016 Ohio 2014-2016 HP 2020 Target*

(Source: Ohio Public Health Data Warehouse, 2014-2016)

What Can I Do to Reduce My Risk of Breast Cancer?

Many factors can influence your breast cancer risk, and most women who develop breast cancer do not have any known risk factors or a history of the disease in their families. However, you can help lower your risk of breast cancer in the following ways:

• Keep a healthy weight. • Exercise regularly (at least four hours a week). • Get enough sleep. • Don’t drink alcohol, or limit alcohol drinks to no more than one per day. • Avoid exposures to chemicals that can cause cancer (carcinogens). • Try to reduce your exposure to radiation during medical tests like mammograms, X-rays, CT scans, and PET scans. • If you are taking, or have been told to take, hormone replacement therapy or oral contraceptives (birth control pills), ask your doctor about the risks and find out if it is right for you. • Breastfeed your babies, if possible.

If you have a family history of breast cancer or inherited changes in your BRCA1 and BRCA2 genes, you may have a higher breast cancer risk. Talk to your doctor about these ways of reducing your risk:

• Anti-estrogens or other medicines that block or decrease estrogen in your body. • Surgery to reduce your risk of breast cancer: — Prophylactic (preventive) mastectomy (removal of breast tissue). — Prophylactic (preventive) salpingo-oophorectomy (removal of the ovaries and fallopian tubes).

(Source: Centers for Disease Control and Prevention, What Can I Do to Reduce My Risk of Breast Cancer? Updated September 27, 2017)

WOMEN’S HEALTH | 41

Health Care Access: Men’s Health

Key Findings Defiance County Male In 2018, 44% of Defiance County males over the age of 50 Leading Causes of Death, 2014 – 2016 had a Prostate-Specific Antigen (PSA) test in the past year. Total Male Deaths: 569 Almost two-fifths (39%) had been diagnosed with high blood pressure, 31% had high blood cholesterol, and 22% 1. Heart Diseases (25% of all deaths) were identified as current smokers, which, along with 2. Cancers (24%) obesity (38%), are known risk factors for cardiovascular 3. Accidents, Unintentional Injuries (9%) diseases. 4. Chronic Lower Respiratory Diseases (6%) 5. Stroke (5%)

Men’s Health Screenings and Concerns (Source: Ohio Public Health Data Warehouse, 2014-2016)

• About two-fifths (41%) of Defiance County males had a Prostate-Specific Antigen (PSA) test at some time in Ohio Male their life, and 24% had one in the past year. Leading Causes of Death, 2014 – 2016 Total Male Deaths: 175,247

• Seventy-one percent (71%) of males age 50 and over 1. Heart Diseases (25% of all deaths) had a PSA test at some time in their life, and 44% had 2. Cancers (23%) one in the past year. 3. Accidents, Unintentional Injuries (8%) 4. Chronic Lower Respiratory Diseases (6%) • Almost half (45%) of men had a digital rectal exam in 5. Stroke (4%) their lifetime, and 10% had one in the past year. (Source: Ohio Public Health Data Warehouse, 2014-2016) • Eighteen percent (18%) of males age 50 and over had a digital rectal exam in the past year.

10% of Defiance County males had a digital rectal exam in the past year.

• In 2018, 7% of men had a heart attack and 3% had a stroke at some time in their life.

• Major risk factors for cardiovascular disease include smoking, obesity, high blood cholesterol, high blood pressure, physical inactivity, and diabetes. In Defiance County, the 2018 health assessment identified that: — 78% of men were overweight or obese (2016 BRFSS reports 71% for Ohio and 71% for the U.S.) — 39% were diagnosed with high blood pressure (2015 BRFSS reports 38% for Ohio and 34% for U.S.) — 31% were diagnosed with high blood cholesterol (2015 BRFSS reports 38% for Ohio and 38% for U.S.) — 22% of all men were current smokers (2016 BRFSS reports 25% for Ohio, and 19% for U.S.) — 14% had been diagnosed with diabetes (2016 BRFSS reports 12% for Ohio and 11% for U.S.)

• From 2014 to 2016, major cardiovascular diseases (heart disease and stroke) accounted for 30% of all male deaths in Defiance County (Source: Ohio Public Health Data Warehouse, 2014-2016).

• From 2014 to 2016, the leading cancer deaths for Defiance County males were lung and bronchus, prostate, and kidney and renal pelvis. Statistics from the same period for Ohio males indicate that lung and bronchus, colon and rectum, and prostate cancers were the leading cancer deaths (Source: Ohio Public Health Data Warehouse, 2014-2016).

MEN’S HEALTH | 42

The following graph shows the percentage of Defiance County males who had various health exams in the past year. Examples of how to interpret the information shown on the graph include: 24% of Defiance County males had a PSA test within the past year, and 10% had a digital rectal exam.

Defiance County Men's Health Exams Within the Past Year 60%

44%

40%

24% 24% 21% 22% 20% 18% 17% 15%

10% 8% 5% 2%

Total Under 50 50 & Older Income <$25K Income >$25K Defiance 2015

Prostate-Specific Antigen (PSA) Digital Rectal

Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

Defiance Defiance Defiance Defiance Ohio U.S. Adult Comparisons County County County County 2016 2016 2008 2012 2015 2018 Had a PSA test in within the past 32% 28% 22% 24% N/A N/A year Had a digital rectal exam within 33% 22% 15% 10% N/A N/A the past year

N/A – Not Available

Prostate Cancer Awareness

• Prostate cancer is the most common cancer among American men. Most prostate cancers grow slowly and don’t cause any health problems in men who have them. • Men can have different symptoms for prostate cancer. Some men do not have symptoms at all. Some symptoms of prostate cancer are difficulty starting urination, frequent urination (especially at night), weak or interrupted flow of urine, and blood in the urine or semen. • There is no way to know for sure if you will get prostate cancer. Men have a greater chance of getting prostate cancer if they are 50 years old or older, are African-American, or have a father, brother, or son who has had prostate cancer. • Two tests are commonly used to screen for prostate cancer: — Digital rectal exam (DRE): A doctor, nurse, or other health care professional places a gloved finger into the rectum to feel the size, shape, and hardness of the prostate gland. — Prostate specific antigen test (PSA): PSA is a substance made by the prostate. The PSA test measures the level of PSA in the blood, which may be higher in men who have prostate cancer. However, other conditions such as an enlarged prostate, prostate infection and certain medical procedures also may increase PSA levels.

(Source: Centers for Disease Control and Prevention, Prostate Cancer Awareness, September 21, 2017)

MEN’S HEALTH | 43

The following graphs show the Defiance County and Ohio age-adjusted mortality rates per 100,000 population for cardiovascular diseases by gender. The graphs show:

• From 2014 to 2016, the Defiance County and Ohio male age-adjusted mortality rates were higher than the female rate for heart disease.

• The Defiance County male age-adjusted stroke mortality rate was higher than the Ohio male rate.

Defiance County Age-Adjusted Heart Disease Mortality Rates By Gender, 2014-2016 300

250 230

200 Male 150 131 Female

100 48 50 27

population 100,000 per Rate 0 Heart Disease Stroke

Ohio Age-Adjusted Heart Disease and Stroke 300 Mortality Rates By Gender, 2014-2016

250 238

200

148 Male 150 Female

100

40 50 40

population 100,000 per Rate 0

Heart Disease Stroke

(Source for graphs: Ohio Public Health Data Warehouse, 2014-2016)

MEN’S HEALTH | 44

The following graph shows the Defiance County age-adjusted lung cancer mortality rates per 100,000 population for men with comparison to the Healthy People 2020 objective. The graph shows:

• From 2014 to 2016, the Defiance County age-adjusted mortality rate for male lung cancer was higher than the Ohio and U.S rates, as well as the Healthy People 2020 objective.

Defiance County Male Age-Adjusted Lung Cancer Mortality Rates

100

62 61

60 49 46 40

population 100,000 per Rate 0 Defiance County 2014-2016 Ohio 2014-2016 U.S. 2014-2016 HP 2020 Target*

Note: The Healthy People 2020 target rates are not gender specific. (Sources: Ohio Public Health Data Warehouse 2014-2016, CDC Wonder 2014-2016, Healthy People 2020)

U.S. Men’s Health Data

• Approximately 12% of adult males ages 18 years or older reported fair or poor health. • 18% of adult males in the U.S. currently smoke. • Of the adult males in the U.S., 32% had 5 or more drinks in 1 day at least once in the past year. • Only 56% of adult males in the U.S. met the 2008 federal physical activity guidelines for aerobic activity through leisure-time aerobic activity. • 35% of men 20 years and over are obese. • There are 12% of males under the age of 65 without health care coverage. • The leading causes of death for males in the United States are heart disease, cancer and accidents (unintentional injuries).

(Source: CDC, National Center for Health Statistics, Men’s Health, Fast Stats, January 20, 2017)

MEN’S HEALTH | 45

Health Care Access: Oral Health

Key Findings

Sixty-three percent (63%) of Defiance County adults visited a dentist or dental clinic in the past year. The top reasons adults gave for not visiting a dentist in the past year were cost (30%); no oral health problems or had not thought of it (23%); and fear, apprehension, nervousness, pain, and dislike going (15%).

Access to Dental Care

• In the past year, 63% of Defiance County adults had visited a dentist or dental clinic, decreasing to 54% of those with incomes less than $25,000.

• The 2016 BRFSS reported that 68% of Ohio adults and 66% of U.S. adults had visited a dentist or dental clinic in the previous 12 months.

• Nearly four-fifths (65%) of Defiance County adults with dental insurance had been to the dentist in the past year, compared to 55% of those without dental insurance.

• When asked the main reason for not visiting a dentist in the last year, 30% said cost; 23% had no oral health problems or had not thought of it; 15% said fear, apprehension, nervousness, pain, and dislike going; 8% had dentures; 7% did not have/know a dentist; 3% could not find a dentist taking new Medicaid patients; 1% said their dentist did not accept their medical coverage; 1% could not get into a dentist; and 1% used the emergency room for dental issues.

Within Within Within 5 or More Adult Oral Health the Past the Past 2 the Past 5 Never years Year Years Years Time Since Last Visit to Dentist/Dental Clinic Males 65% 15% 8% 10% <1% Females 61% 10% 11% 16% 0%

Total 63% 12% 9% 14% <1%

Defiance Defiance Defiance Defiance Ohio U.S. Adult Comparisons County County County County 2016 2016 2008 2012 2015 2018 Adults who had visited the dentist 64% 65% 65% 63% 68% 66% or dental clinic in the past year

ADULT ORAL HEALTH | 46

The following graph indicates the percentage of Defiance County adults who visited a dentist or dental clinic in the past year. Examples of how to interpret the information include: 63% of all Defiance County adults had been to the dentist or dental clinic in the past year, including 65% of males and 54% of those with incomes less than $25,000.

Defiance County Adults Visiting a Dentist or Dental Clinic in the Past Year* 100%

80% 67% 65% 66% 64% 65% 65% 63% 61% 63% 60% 57% 54%

40%

20%

0% Total Males Females Under 30 30-64 65 & Income Income Defiance Defiance Defiance Years Over <$25K >$25K 2008 2012 2015

*Totals may not equal 100% as some respondents answered do not know. Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

Facts About Adult Oral Health

• The baby boomer generation is the first where most people will keep their natural teeth over their entire lifetime. This is largely because of the benefits of water fluoridation and fluoride toothpaste. However, threats to oral health, including tooth loss, continue throughout life.

• The major risks for tooth loss are tooth decay and gum disease that may increase with age because of problems with saliva production; receding gums that expose “softer” root surfaces to decay-causing bacteria; or difficulties flossing and brushing because of poor vision, cognitive problems, chronic disease, and physical limitations.

• Although more adults are keeping their teeth, many continue to need treatment for dental problems. This need is even greater for members of some racial and ethnic groups—about 3 in 4 Hispanics and non-Hispanic black adults have an unmet need for dental treatment, as do people who are poor. These individuals are also more likely to report having poor oral health.

• In addition, some adults may have difficulty accessing dental treatment. For every adult aged 19 years or older without medical insurance, there are three who don’t have dental insurance.

• Oral health problems include the following: untreated tooth decay, gum disease, tooth loss, oral cancer, and chronic diseases such as arthritis, heart disease, and strokes.

(Source: Centers for Disease Control and Prevention, Division of Oral Health, Adult Oral Health, October 23, 2017)

ADULT ORAL HEALTH | 47 Health Behaviors: Health Status Perceptions

Key Findings Adults Who Rated General Health In 2018, nearly half (46%) of Defiance County adults rated their health Status Excellent or Very Good status as excellent or very good. Conversely, 15% of adults described their health as fair or poor, increasing to 24% of those with incomes • Defiance County 46% (2018) less than $25,000. • Ohio 51% (2016)

• U.S. 52% (2016)

General Health Status (Source: 2016 BRFSS for Ohio and U.S.) • In 2018, nearly half (46%) of Defiance County adults rated their health as excellent or very good. Defiance County adults with higher incomes (46%) were most likely to rate their health as excellent or very good, compared to 43% of those with incomes less than $25,000.

• Fifteen percent (15%) of adults rated their health as fair or poor. The 2016 BRFSS has identified that 18% of Ohio and 17% of U.S. adults self-reported their health as fair or poor.

• Defiance County adults were most likely to rate their health as fair or poor if they: — Had been diagnosed with diabetes (38%) — Were widowed (28%) — Had an annual household income less than $25,000 (24%) — Had high blood pressure (23%)

Mental Health Status

• In 2018, 28% of Defiance County adults rated their mental health as not good on four or more days in the previous month.

• Defiance County adults reported their mental health as not good on an average of 3.4 days in the previous month. Ohio and U.S. adults reported their mental health as not good on an average of 4.3 days and 3.8 days, respectively, in the previous month (Source: 2016 BRFSS as compiled by 2018 County Health Rankings).

• One-third (33%) of adults reported that poor mental or physical health kept them from doing usual activities such as self-care, work, or recreation.

• Defiance County adults were most likely to rate their mental health as not good if they: — Had an annual household income less than $25,000 (56%) — Were female (43%)

Common Signs of Mental Illness in Adults

• Trying to tell the difference between what expected behaviors are and what might be the signs of a mental illness isn’t always easy. There’s no easy test that can let someone know if there is mental illness or if actions and thought might be typical behaviors of a person or the result of a physical illness.

• Each illness has its own symptoms, but common signs of mental illness in adults can include: — Excessive worrying or fear — Feeling excessively sad or low — Extreme mood changes — Avoiding friends and social activities — Changing in sleeping habits or feeling tired and low energy — Abuse of substances like alcohol or drugs — Inability to carry out daily activities or handle daily problems and stress

(Source: National Alliance on Mental Illness, Know the Warning Signs, 2018)

ADULT HEALTH STATUS PERCEPTIONS | 48 The following graph shows the percentage of Defiance County adults who described their personal health status as excellent/very good, good, and fair/poor. Examples of how to interpret the information include: 46% of all Defiance County adults, 44% of males, and 38% of those ages 65 and older rated their health as excellent or very good.

Defiance County Adult Health Perceptions* 100% 7% 15% 15% 14% 16% 12% 13% 17% 12% 14% 22% 24% 80% 34% 37% 39% 37% 42% 34% 41% 43% 60% 40% 33%

40% 79% 53% 51% 46% 44% 49% 46% 49% 20% 41% 38% 43%

0% Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

Excellent/Very Good Good Fair/Poor

*Respondents were asked: “Would you say that in general your health is excellent, very good, good, fair or poor?” Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

Defiance Defiance Defiance Defiance Ohio U.S. Adult Comparisons County County County County 2016 2016 2008 2012 2015 2018 Rated health as excellent or very 53% 49% 51% 46% 51% 52% good Rated health as fair or poor 13% 17% 12% 15% 18% 17% Average days that mental health N/A N/A N/A 3.4 4.3* 3.8* not good in past month N/A – Not Available *2016 BRFSS as compiled by 2018 County Health Rankings

ADULT HEALTH STATUS PERCEPTIONS | 49 Health Behaviors: Adult Weight Status

Key Findings

Adult Weight Status

• Almost three-fourths (72%) of Defiance County adults were either overweight (32%) or obese (40%) by Body Mass Index (BMI), putting them at elevated risk for developing a variety of diseases.

• More than two-fifths (41%) of adults were trying to lose weight, 36% were trying to maintain their current weight or keep form gaining weight, and 3% were trying to gain weight.

40% of Defiance County adults were obese.

Physical Activity

• In Defiance County, 51% of adults engaged in some type of physical activity or exercise for at least 30 minutes on 3 or more days per week. Thirty percent (30%) of adults exercised 5 or more days per week. About one- quarter (23%) of adults did not participate in any physical activity in the past week.

• The CDC recommends that adults participate in moderate exercise for at least 2 hours and 30 minutes every week or vigorous exercise for at least 1 hour and 15 minutes every week. Whether participating in moderate or vigorous exercise, the CDC also recommends muscle-strengthening activities that work all major muscle groups on 2 or more days per week (Source: U.S. Department of Health and Human Services, 2008 Physical Activity Guidelines for Americans).

• Reasons for not exercising included the following: time (45%); weather (39%); laziness (35%); too tired (30%); pain or discomfort (30%); did not like to exercise (21%); could not afford a gym membership (16%); no exercise partner (12%); did not know what activities to do (9%); lack of opportunities for those with physical impairments or challenges (6%); poorly maintained/no sidewalks (5%); no child care (5%); no walking, biking trails or parks (4%); doctor advised them not to exercise (3%); no gym available (3%); transportation (1%); and neighborhood safety (<1%).

• Adults spent the most time doing the following physical activities in the past year: walking (32%), cycling (4%), exercise machines (3%), running/jogging (2%), strength training (1%), swimming (<1%), and other activities (5%). Fifteen percent (15%) of adults did not exercise at all, including 4% who were unable to do so. One-third (33%) of adults participated in multiple types of physical activity.

• Defiance County adults spent an average of 2.7 hours watching TV, 2.1 hours on the computer/tablet, 1.5 hours on their cell phone, and 0.2 hours playing video games on an average day of the week.

• The following describes what Defiance County adults did at work: mostly sitting (19%), mostly walking (13%), mostly heavy labor or physically demanding work (10%), and mostly standing (6%). Twenty-three percent (23%) of adults indicated that their workplace activity level varied from week to week.

Defiance Defiance Defiance Defiance Ohio U.S. Adult Comparisons County County County County 2016 2016 2008 2012 2015 2018

Obese 35% 35% 36% 40% 32% 30%

Overweight 32% 39% 34% 32% 35% 35%

ADULT WEIGHT STATUS | 50 The following graph shows the percentage of Defiance County adults who were overweight or obese by Body Mass Index (BMI). Examples of how to interpret the information include: 27% of all Defiance County adults were classified as normal weight, 32% were overweight, and 40% were obese.

Defiance County Adult BMI Classifications* 100%

30% 80% 38% 37% 35% 35% 40% 41% 39% 36% 45% 45% 60% 31% 32% 24% 39% 34% 40% 32% 40% 40% 20% 35% 30%

20% 39% 32% 31% 27% 30% 25% 24% 27% 21% 23% 22% 0% Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

Normal Overweight Obese

*Percentages may not equal 100% due to the exclusion of data for those who were classified as underweight Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

Nutrition

• In 2018, 37% of adults ate 1 to 2 servings of fruits and vegetables per day, 36% ate 3 to 4 servings per day, and 24% ate 5 or more servings per day. Three percent (3%) of adults ate no servings of fruits and vegetables per day.

• The American Cancer Society recommends that adults eat at least 2½ cups of fruits and vegetables per day to reduce the risk of cancer and to maintain good health (Source: American Cancer Society, 2017).

• Defiance County adults reported the following barriers to consuming fruits and vegetables: too expensive (14%), they did not like the taste (4%), did not have access to fruits and vegetables (2%), no variety (1%), transportation (1%), and other barriers (2%).

• Defiance County adults reported the following reasons they chose the types of food they ate: taste/enjoyment (70%), cost (57%), healthiness of food (48%), ease of preparation/time (43%), what their family prefers (41%), food they were used to (39%), nutritional content (26%), availability (26%), calorie content (23%), artificial sweetener content (9%), if it is genetically modified (7%), if it is organic (6%), health care provider’s advice (5%), if it is gluten free (5%), other food sensitivities (5%), if it is lactose free (4%), and limitations set by WIC (1%).

• In a typical week, adults ate out in a restaurant or brought home take-out food at the following frequencies: 1 to 2 times (58%), 3 to 4 times (19%), 5 or more times (6%). Seventeen percent (17%) of adults reported they did not eat out or bring takeout home to eat in a typical week.

ADULT WEIGHT STATUS | 51 The Food Environment Index measures the quality of the food environment in a county on a scale from 0 to 10 (zero being the worst value in the nation, and 10 being the best). The two variables used to determine the measure are limited access to healthy foods & food insecurity.

• The food environment index in Defiance County is 8.3.

• The food environment index in Ohio is 6.6.

Defiance County had a

food index measure of:

8.3

(Source: USDA Food Environment Atlas, as compiled by County Health Rankings 2018)

ADULT WEIGHT STATUS | 52 Health Behaviors: Adult Tobacco Use

Key Findings

In 2018, 19% of Defiance County adults were current smokers, and 21% were considered former smokers. Six percent (6%) of adults used vaping products in the past year. Over half (52%) of Defiance County adults did not know if e-cigarette vapor was harmful to themselves or others.

Adult Tobacco Use Behaviors

• In 2018, nearly one-in-five (19%) Defiance County adults were current smokers (those who indicated smoking at least 100 cigarettes in their lifetime and currently smoked some or all days). The 2016 BRFSS reported current smoker prevalence rates of 23% for Ohio and 17% for the U.S.

• About one-fifth (21%) of adults indicated that they were former smokers (smoked 100 cigarettes in their lifetime and now do not smoke). The 2016 BRFSS reported former smoker prevalence rates of 24% for Ohio and 25% for the U.S.

• Defiance County adult smokers were more likely to have: — Been married (50%) — Been male (22%) — Incomes less than $25,000 (20%)

• Defiance County adults used the following tobacco products in the past year: cigarettes (21%), cigars (6%), chewing tobacco (4%) vaping products (6%), Black and Milds (4%), hookah (1%), Swishers (1%), cigarillos (1%), little cigars (1%), and pouch (1%).

• More than two-fifths (41%) of current smokers responded that they had stopped smoking for at least one day in the past year because they were trying to quit smoking.

• Defiance County adults had the following rules/practices about smoking in their home: never allowed (71%), not allowed when children are present (9%), allowed anywhere (9%), and allowed in certain rooms (5%).

• Adults had the following rules/practices about smoking in their car: never allowed (74%), not allowed when children are present (10%), allowed with windows open (7%), and allowed anywhere (7%).

• Defiance County adults would support an ordinance to ban smoking in the following places: vehicle with a minor present (72%), parks or ball fields (54%), multi-unit housing (52%), fairgrounds (51%), and college/university campuses (50%). About one-fourth (24%) of adults would not support any ordinance to ban smoking.

• More than two-fifths (42%) of adults believed that e-cigarette vapor was harmful to themselves. Two-fifths (40%) of adults believed that e-cigarette vapor was harmful to others, and 5% did not believe it was harmful to anyone. Over half (52%) of adults did not know if e-cigarette vapor was harmful to themselves or others.

Defiance Defiance Defiance Defiance Ohio U.S. Adult Comparisons County County County County 2016 2016 2008 2012 2015 2018 Current smoker (currently smoke some 21% 18% 15% 19% 23% 17% or all days) Former smoker (smoked 100 cigarettes 29% 26% 21% 21% 24% 25% in lifetime & now do not smoke) Tried to quit smoking (on at least one 65% 68% 53% 41% N/A N/A day in the past year) N/A – Not Available ADULT TOBACCO USE | 53

The following graph shows the percentage of Defiance County adults’ smoking behaviors. Examples of how to interpret the information include: 19% of all Defiance County adults were current smokers, 21% of all adults were former smokers, and 60% had never smoked.

Defiance County Adult Smoking Behaviors* 100%

80% 48% 54% 55% 50% 56% 60% 65% 60% 64% 72% 60% 86%

40% 30% 25% 29% 21% 26% 37% 15% 23% 21% 13% 20% 0% 22% 19% 15% 21% 20% 17% 21% 18% 15% 14% 8% 0% Total Male Female Under 30 30-64 65 Years & Income Income Defiance Defiance Defiance Years Years Over <$25K $25K Plus 2008 2012 2015

Current smoker Former smoker Never smoked

*Respondents were asked: “Have you smoked at least 100 cigarettes in your entire life? If yes, do you now smoke cigarettes every day, some days or not at all?” Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

41% of current smokers responded that they had stopped smoking for at least one day in the past year because they were trying to quit smoking.

The following graph shows Defiance County, Ohio, and U.S. adult cigarette smoking rates. The BRFSS rates shown for Ohio and the U.S. were for adults 18 years and older. This graph shows:

• The Defiance County adult cigarette smoking rate was lower than the Ohio rate, but higher than the U.S. rate and the Healthy People 2020 objective.

Healthy People 2020 Objective & Cigarette Smoking Rates 40%

30% 23% 19% 20% 17% 12% 10%

0% Defiance County 2018 Ohio 2016 U.S. 2016 HP 2020 Target

(Source: 2018 Defiance County Health Assessment, 2016 BRFSS and Healthy People 2020)

ADULT TOBACCO USE | 54

The following graphs show Defiance County, Ohio, and U.S. age-adjusted mortality rates per 100,000 populations for chronic lower respiratory diseases (formerly COPD), as well as lung and bronchus cancer in comparison with the Healthy People 2020 objective. These graphs show:

• From 2014 to 2016, Defiance County’s age-adjusted mortality rate for Chronic Lower Respiratory Disease was higher than the Ohio and U.S. rates, but lower than the Healthy People 2020 target objective.

• Defiance County’s age-adjusted mortality rate for lung and bronchus cancer was higher than Ohio and U.S. rates, as well as the Healthy People 2020 target objective.

Age-Adjusted Mortality Rates for Chronic Lower Respiratory Diseases (Formerly COPD)

120 103 100 80 58 60 48 41 40 20

Rate per 100,000 population 100,000 per Rate

Defiance County 2014-2016 Ohio 2014-2016 U.S. 2014-2016 HP 2020 Target*

*The Healthy People 2020’s target rate and the U.S. rate is for adults ages 45 years and older. (Source: Ohio Public Health Data Warehouse 2014-2016, CDC Wonder 2014-2016 and Healthy People 2020)

100 Age-Adjusted Mortality Rates for Lung & Bronchus Cancer

60 52 49 42 46 40

Rate per 100,000 population 100,000 per Rate Defiance County 2014-2016 Ohio 2014-2016 U.S. 2014-2016 HP 2020 Target*

*The Healthy People 2020 target objective only includes the age-adjusted lung cancer death rate (Source: Ohio Public Health Data Warehouse 2014-2016, CDC Wonder 2014-2016 and Healthy People 2020)

ADULT TOBACCO USE | 55

The following graph shows the Defiance County age-adjusted mortality rates for lung and bronchus cancer by gender. The graph shows:

• Disparities existed by gender for Defiance County lung and bronchus cancer age-adjusted mortality rates. From 2014 to 2016, the Defiance County male rate was higher than the female rate.

Age-Adjusted Mortality Rates by Gender for

Lung & Bronchus Cancer

100

62 60 45 40 20

Rate Rate per 100,000 population Defiance County Males 2014-2016 Defiance County Females 2014-2016

(Source: Ohio Public Health Data Warehouse 2014-2016)

Smoking and Other Health Risks

• Smoking can make it harder for a woman to become pregnant and can affect her baby's health before and after birth. Smoking increases risks for: — Preterm (early) delivery — Stillbirth (death of the baby before birth) — Low birth weight — Sudden infant death syndrome (known as SIDS or crib death) — Ectopic pregnancy — Orofacial clefts in infants

• Smoking can also affect men's sperm, which can reduce fertility and also increase risks for birth defects and miscarriage (loss of the pregnancy).

• Smoking can affect bone health. — Women past childbearing years who smoke have lower bone density (weaker bones) than women who never smoked and are at greater risk for broken bones.

• Smoking affects the health of your teeth and gums and can cause tooth loss

• Smoking can increase your risk for cataracts (clouding of the eye’s lens that makes it hard for you to see) and age-related macular degeneration (damage to a small spot near the center of the retina, the part of the eye needed for central vision).

• Smoking is a cause of type 2 diabetes mellitus and can make it harder to control. The risk of developing diabetes is 30-40% higher for active smokers than nonsmokers.

• Smoking causes general adverse effects on the body, including inflammation and decreased immune function.

• Smoking is a cause of rheumatoid arthritis.

(Source: CDC, Effects of Cigarette Smoking, Smoking and Other Health Risks, updated May 15, 2017)

ADULT TOBACCO USE | 56

Health Behaviors: Adult Alcohol Consumption

Key Findings

Fifty-six percent (56%) of Defiance County adults had at least one alcoholic drink in the past month. One-quarter (25%) of Defiance County adults reported they had five or more alcoholic drinks (for males) or 4 or more drinks (for females) on an occasion in the last month and would be considered binge drinkers. Twenty-eight percent (28%) of adults drove a vehicle or other equipment after consuming any alcoholic beverages.

Adult Alcohol Consumption

• In 2018, 56% of the Defiance County adults had at least one alcoholic drink in the past month, increasing to 67% of males. The 2016 BRFSS reported current drinker prevalence rates of 53% for Ohio and 54% for the U.S.

• Of those who drank, Defiance County adults drank 3.7 drinks on average, increasing to 4.4 drinks for males.

• One-quarter (25%) of Defiance County adults reported they had five or more alcoholic drinks (for males) or 4 or more drinks (for females) on an occasion in the last month and would be considered binge drinkers. The 2016 BRFSS reported binge drinking rates of 18% for Ohio and 17% for the U.S. Of those who drank in the past month, 48% had at least one episode of binge drinking.

25% of Defiance County adults were considered binge drinkers

• Defiance County adults drove the following after having 5 or more alcoholic beverages: motor vehicle (8%), boat (<1%), and other (4%). No one reported driving a watercraft, ATV, snowmobile, farm machinery, or motorcycle after having 5 or more alcoholic beverages.

• Twenty-eight percent (28%) of adults reported driving a vehicle after drinking any alcoholic beverage.

• Defiance County adults experienced the following in the past 6 months: drove a vehicle or other equipment after having any alcoholic beverages (15%); drank more than they expected (7%); used prescription drugs while drinking (5%); drank more to get the same effect (4%); spent a lot of time drinking (3%); continued to drink despite problems caused by drinking (2%); tried to quit or cut down but could not (2%); gave up other activities to drink (2%); drank to ease withdrawal symptoms (1%); and failed to fulfill duties at home, work, or school (1%).

• Two percent (2%) of Defiance County adults used a program to help with an alcohol or drug problem for themselves or a loved one. Reasons for not using such a program included the following: had not thought of it (3%), fear (1%), could not afford to go (1%), did not know how to find a program (1%), transportation (<1%), program was not available (<1%), and other reasons (1%). Ninety-five percent (95%) of adults indicated such a program was not needed.

Defiance Defiance Defiance Defiance Ohio U.S. Adult Comparisons County County County County 2016 2016 2008 2012 2015 2018 Current drinker (drank alcohol at least 52% 53% 49% 56% 53% 54% once in the past month) Binge drinker (defined as consuming more than four [women] or five [men] alcoholic 20% 20% 23% 25% 18% 17% beverages on a single occasion in the past 30 days)

ADULT ALCOHOL CONSUMPTION | 57 The following graphs show the percentage of Defiance County adults who consumed alcohol and the amount consumed on average in the past month. Examples of how to interpret the information shown on the first graph include: 42% of all Defiance County adults did not drink alcohol, 33% of Defiance County males did not drink, and 48% of adult females reported they did not drink.

Defiance County Average Number of Days Drinking Alcohol in the Past Month* 100%

90%

30% 35% 80% 36% 31% 33% 45% 43% 45% 45% 70% 55% 71% 60% 12% 13% 17% 15% 50% 16% 11% 10% 9% 13% 40% 10% 30% 57% 48% 7% 48% 47% 20% 42% 43% 44% 40% 45% 33% 10% 21% 0% Total Male Female Under 30 30-64 65 & Over Income Income Defiance Defiance Defiance Years <$25K $25K Plus 2008 2012 2015

Did not drink any 1-2 days 3 or more days

*Percentages may not equal 100% as some respondents answered, “don’t know”

Defiance County Adult Average Number of Drinks Consumed Per Drinking Occasion 5 4.4 4.4 4.0 4 3.7 3.5 3.3

3 2.8 2.8 2.4 2.5 2.5

0 Total Males Females Under 30 30-64 65 & Over Income Income Defiance Defiance Defiance Years <$25K >$25K 2008 2012 2015

Note for graphs: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

ADULT ALCOHOL CONSUMPTION | 58 The following graph shows a comparison of Defiance County binge drinkers with Ohio and U.S. binge drinkers.

• In 2018, Defiance County had a larger percentage of binge drinkers in comparison to Ohio and U.S. rates.

Defiance County Adult Binge Drinkers in the Past Month*

40%

30% 25% 20% 18% 17%

10%

Defiance County 2018 Ohio 2016 U.S. 2016

(Source: 2016 BRFSS, 2018 Defiance County Health Assessment) *Based on all adults. Binge drinking is defined as males having five or more drinks on an occasion, females having four or more drinks on one occasion.

Economic Costs of Excessive Alcohol Use

• Excessive alcohol consumption cost the United States $249 billion in 2010. This cost amounts to about $2.05 per drink, or about $807 per person.

• Costs due to excessive drinking largely resulted from loses in workplace productivity (72% of the total cost), health care expenses (11%), and other costs due to a combination of criminal justice expenses, motor vehicle crash costs, and property damage.

• Excessive alcohol use cost states and DC a median of 3.5 billion in 2010, ranging from $488 million in North America to $35 billion in California.

• Excessive alcohol consumption cost Ohio $8.5 billion in 2010. This cost amounts to $2.10 per drink or $739 per person.

• Binge drinking, defined as consuming 4 or more drinks per occasion for women or 5 or more drinks per occasion for men, was responsible for 77% of the cost of excessive alcohol use in all states and DC.

• About $2 of every $5 of the economic costs of excessive alcohol use were paid by federal, state, and local governments.

(Source: CDC, Alcohol and Public Health – Excessive Drinking, updated June 15, 2018)

ADULT ALCOHOL CONSUMPTION | 59 The following table shows the City of Defiance, Defiance County, and Ohio motor vehicle accident statistics. The table shows:

• In 2017, 4% of the total crashes in Defiance County were alcohol-related, compared to 4% for Ohio.

• Of the total number of alcohol-related crashes (43) in Defiance County, 51% were property damage only, 40% were non-fatal injury, and 9% were fatal injury.

• There were 11,928 alcohol-related crashes in Ohio in 2017. Of those crashes, 56% were property damage only, 41% were non-fatal injury, and 3% were fatal injury.

City of Defiance Ohio Defiance County 2017 2017 2017 Crashes Property Damage Only (PDO) Crashes 394 949 226,753 Injury Crashes 103 220 75,434 Fatal Injury Crashes 3 9 1,094 Total Crashes 500 1,178 303,281 Drivers Total Drivers in Crashes 864 1,700 507,868 Alcohol Impaired Drivers in Crashes 18 43 11,666 Total Passengers in Crashes 390 687 179,663 Alcohol-Related Property Damage Only (PDO) 10 22 6,733 Injury (non-fatal) 7 17 4,898 Fatal Injury 1 4 297 Total Alcohol-Related Crashes 18 43 11,928 Alcohol-Related Deaths 1 4 314

(Source: Ohio Department of Public Safety, Crash Reports, Updated 8/20/2018, Traffic Crash Facts)

ADULT ALCOHOL CONSUMPTION | 60 Health Behaviors: Adult Drug Use

Key Findings

Adult Drug Use

• Four percent (4%) of Defiance County adults had used marijuana in the past 6 months.

• Five percent (5%) of Defiance County adults reported using other recreational drugs in the past 6 months such as cocaine, synthetic marijuana/K2, heroin, LSD, inhalants, Ecstasy, bath salts, and methamphetamine.

• Six percent (6%) of adults had used medication not prescribed for them or they took more than prescribed to feel good or high and/or more active or alert during the past 6 months.

• Adults misused the following over-the-counter drugs in the past 6 months: cold and cough medicine (9%), sleeping pills (2%), motion sickness pills (1%), and other drugs (1%).

• Defiance County adults indicated they did the following with their unused prescription medication: took as prescribed (23%), kept them (17%), threw them in the trash (15%), took them to the medication collection program (12%), flushed them down the toilet (12%), took them to the sheriff’s office (11%), took them in on Drug Take Back Days (8%), kept them in a locked cabinet (1%), gave them away (1%), mailer to ship back to pharmacy (<1%), and some other destruction method (1%). Forty-four percent (44%) of adults did not have unused medication.

Defiance Defiance Defiance Defiance Ohio U.S. Adult Comparisons County County County County 2016 2016 2008 2012 2015 2018 Adults who used marijuana in the past 6 5% 4% 4% 4% N/A N/A months Adults who misused prescription 1% 7% 3% 6% N/A N/A medication in the past 6 months N/A- Not Available

ADULT DRUG USE | 61 The following graphs show adult marijuana use and medication misuse in the past 6 months. Examples of how to interpret the information on the first graph include: 4% of all Defiance County adults used marijuana in the past 6 months, 6% of males were current users, and 3% of adults with incomes less than $25,000 were current users.

10% Defiance County Adult Marijuana Use in Past 6 Months

6% 5% 5% 5% 4% 4% 4% 4%

3% 2% 2%

0% 0% Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

Defiance County Adult Prescription Medication Misuse in Past 6 Months 15%

10% 10% 9%

7% 7% 7% 6% 6% 5% 5%

1% 0% 0% Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

Note for graphs: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

ADULT DRUG USE | 62 The following graphs are data from the Ohio Automated Prescription Reporting System (OARRS) indicating Defiance County and Ohio opiate and pain reliever doses per patient, as well as doses per capita.

Defiance County and Ohio Number of Opiate and Pain Reliever Doses Per Patient, 2012-2017 300 280 274 266 265 254 250 250 232 232 222 220 215 204 200

150

100

Doses per Patient Doses Patient per 50

0 2012 2013 2014 2015 2016 2017

Defiance County Ohio

Defiance County and Ohio Number of Opiate and Pain Reliever

Doses Per Capita, 2012-2017 120

100

68.7 67.4 65.1 60.8 60 54.0 55.3 55.6 55.1 50.1 49.3 44.0 40.2 40 Doses per Capita 20

0 2012 2013 2014 2015 2016 2017 Defiance County Ohio

(Source for graphs: Ohio’s Automated Rx Reporting System, 2012-2017)

ADULT DRUG USE | 63 The following graphs show Defiance County and Ohio quarterly opiate doses per capita.

Defiance County and Ohio Number of Opioid Doses Per Capita, 18 Quarterly from 2016 to 2017

14.2 13.5 14 12.8 12.5 12.0 12.1 11.6 12 11.2 10.7 10.3 Doses per Capita 10.1 9.9 10.0 10 9.2 9.4 8.5

8 2016 2016 2016 2017 2017 2017 2017 2018 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1

Defiance County Ohio

(Source: Ohio’s Automated Rx Reporting System, 2016-2017)

Ohio Automated Rx Reporting System (OARRS)

• OARRS has been collecting information from all Ohio-licensed pharmacies and Ohio personal licensed prescribers regarding outpatient prescriptions for controlled substance since 2006. — All data reported is updated every 24 hours and is maintained in a secure database. • OARRS aims to be a reliable tool in addressing prescription drug diversion and abuse. • With many features such as a patient care tool, epidemic early warning system, drug diversion and insurance fraud investigation tool, OARRS is the only statewide electronic database that helps prescribers and pharmacists avoid potential life-threatening drug interactions. — OARRS also works in limiting patients who “doctor shop” which refers to individuals fraudulently obtaining prescriptions from multiple health care providers for the same or multiple prescription for abuse or illegal distribution. • Additionally, OARRS is also used for investigating and identifying health care professionals with continual inappropriate prescribing and dispensing to patients, and then aids in law enforcement cases against such acts.

(Source: Ohio Automated RX Reporting System; What is OARRS?, Updated August 15, 2017)

ADULT DRUG USE | 64 The following graphs show the number of prescription opiate related drug overdose deaths and unintentional drug overdose deaths from 2011-2016 in Defiance County.

Defiance County Number of Prescription Opiate Related Drug Overdose Deaths, 2011-2016 5 Total Deaths = 13

4 4

3 3 3

2 2

Number of Deaths 1 1 0 0 2011 2012 2013 2014 2015 2016

Defiance County Age Adjusted Unintentional Drug Overdose Death Rate per 100,000 Population 2011-2016 8 Total Deaths = 33 7 7 7 6 6 5 5 5

4 3 3

Per 100,000 Population 100,000 Per 1

0 2011 2012 2013 2014 2015 2016

(Source for graphs: Ohio Public Health Data Warehouse, 2011-2016)

ADULT DRUG USE | 65 Average Age-Adjusted Unintentional Drug Overdose Death Rate Per 100,000 Population, by County, 2011-2016

• The Ohio age-adjusted unintentional drug overdose death rate for 2011-2016 was 23.1 deaths per 100,000 population.

• Defiance County’s age-adjusted unintentional drug overdose death rate for 2011-2016 was 16.0 deaths per 100,000 population.

(Sources: “2016 Ohio Drug Overdoes Data: General Findings,” Ohio Department of Health; Ohio Department of Health, Bureau of Vital Statistics; analysis conducted by ODH Violence and Injury Prevention Program; U.S. Census Bureau (Vintage 2016 population estimates)

Note: Includes Ohio residents who died due to unintentional drug poisoning (underlying cause of death ICD-10 codes X40-X44). Rate suppressed if < 10 total deaths for 2011-2016.

ADULT DRUG USE | 66 Health Behaviors: Adult Sexual Behavior

Key Findings

In 2018, 69% of Defiance County adults had sexual intercourse in the past year. One percent (1%) of adults had more than one partner. Seven percent (7%) of Defiance County adults reported being forced to participate in sexual activity when they did not want to, increasing to 12% of females. Of those who were forced to have sexual activity, 27% reported it.

Adult Sexual Behavior

• Sixty-nine percent (69%) of Defiance County adults had sexual intercourse in the past year.

• One percent (1%) of adults reported they had intercourse with more than one partner in the past year.

• Defiance County adults used the following methods of birth control: vasectomy (24%), they or their partner were too old (19%), tubes tied (18%), condoms (14%), hysterectomy (10%), birth control pill (7%), withdrawal (7%), ovaries or testicles removed (4%), rhythm method (4%), IUD (3%), infertility (3%), shots (3%), and contraceptive implants (<1%).

• Eighteen percent (18%) of Defiance County adults did not use any method of birth control.

• Seven percent (7%) of Defiance County adults reported being forced to have sexual activity when they did not want to, increasing to 12% of females. Of those who were forced to participate in sexual activity, 27% reported it.

• Defiance County adults were diagnosed or treated for the following sexually transmitted diseases in the past 5 years: human papilloma virus (HPV) (2%), chlamydia (1%), genital herpes (1%), hepatitis C (1%), multiple STDs (1%), HIV/AIDS (<1%), and syphilis (<1%).

• Almost one-fourth (24%) of adults had been tested for HIV, not including tests as part of a blood donation.

• Fourteen percent (14%) of adults engaged in sexual activity following alcohol or other drugs that they would not have done if sober.

Defiance Defiance Defiance Defiance Ohio U.S. Adult Comparisons County County County County 2016 2016 2008 2012 2015 2018 Had more than one sexual partner in past 7% 4% 4% 1% N/A N/A year N/A – Not Available

ADULT SEXUAL BEHAVIOR | 67 The following graph shows the number of sexual partners Defiance County adults had in the past year. Examples of how to interpret the information in the graph include: 67% of all Defiance County adults had one sexual partner in the past 12 months, and 1% had more than one; additionally, 69% of males had one partner in the past year.

Defiance County Number of Sexual Partners in the Past Year* 100% 7%

0% 31% 29% 29% 80% 32% 29% 32% 26% 42% 2% 2% 61% 37% 1% 1% 2% 7% 4% 4% 60% 0%

93% 40% 2% 72% 67% 69% 67% 67% 66% 58% 62% 59%

20% 37%

0% Total Male Female Under 30 30-64 65 Years Income Income Defiance Defiance Defiance

Years Years & Over <$25K $25K Plus 2008 2012 2015

One More than one None

*Respondents were asked: “During the past 12 months, with how many different people have you had sexual intercourse?” Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

Understanding Sexual Violence

• Sexual violence is a very serious public health that affects millions of women and men. In the United States, 1 in 5 women have experienced completed or attempted rape, and about 1 in 15 men have been made to penetrate someone in their lifetime. Most victims first experienced sexual violence before the age of 25.

• Statistics underestimate the problem because many victims do not tell the police, family, or friends about the violence.

• Sexual violence is any sexual activity where consent is not freely given. This includes completed or attempted sex acts that are against the victims will or involve a victim who is unable to consent. Sexual violence also includes: — Unwanted sexual contact or — Non-contact, unwanted sexual experiences (such as verbal sexual harassment)

• Sexual violence can be committed by anyone including: — A current or former intimate partner — A family member — A person in position of power or trust — A friend or acquaintance — A stranger, or someone known only by sight

• Sexual violence impacts health in many ways and can lead to long-term physical and mental health problems. For example, victims may experience chronic pain, headaches, and sexually transmitted diseases. They are often fearful or anxious and may have problems trusting others. Anger and stress can lead to eating disorders, depression, and even suicidal thoughts.

(Source: CDC, Sexual Violence, last updated April 4, 2018)

ADULT SEXUAL BEHAVIOR | 68 The following graphs show Defiance County chlamydia disease rates per 100,000 population and the number of chlamydia disease cases. The graphs show:

• Defiance County chlamydia rates increased from 2013 to 2017.

• The number of chlamydia cases in Defiance County gradually increased from 2013 to 2017.

Chlamydia Annualized Disease Rates for Defiance County and Ohio

600

500 521.8 528.9 490.0 468.4 400 460.7 411.4 300 350.4 359.0 339.0 295.7 200

100

Population 100,000 per Rate 0

2013 2014 2015 2016 2017

Defiance County Ohio

Annualized Count of Chlamydia Cases for Defiance County

200

157

137 135 130 100 114

Number of cases reported

0 2013 2014 2015 2016 2017

(Source for graphs: ODH, STD Surveillance, data reported through 5-24-18)

ADULT SEXUAL BEHAVIOR | 69 The following graphs show Defiance County gonorrhea disease rates per 100,000 population and the number of gonorrhea disease cases. The graphs show:

• The Defiance County gonorrhea rate increased from 2016 to 2017.

• The number of gonorrhea cases in Defiance County varied from 2013 to 2017.

Gonorrhea Annualized Disease Rates for Defiance County and Ohio 250

206.6 200 176.8

144 145.0 150 138.3

100

54.8 50 34.1

population 100,000 per Rate 23.4 23.3 18.8 0 2013 2014 2015 2016 2017 Defiance County Ohio

Annualized Count of Gonorrhea Cases for Defiance County 25 21

15 13 9 9 10 8

Number of cases reported 5

0 2013 2014 2015 2016 2017

(Source for graphs: ODH, STD Surveillance, data reported through 5-24-18)

ADULT SEXUAL BEHAVIOR | 70 Health Behaviors: Adult Mental Health

Key Findings Mental Health in the U.S.

In 2018, 2% of Defiance County adults considered • 3.6% of adults aged 18 and over experienced attempting suicide. Eleven percent (11%) of adults felt serious psychological distress in the past 30 days so sad or hopeless almost every day for two weeks or • There were 65.9 million visits to physicians’ offices more in a row that they stopped doing usual activities. with mental disorders as the primary diagnosis • There were 5.0 million visits to emergency Adult Mental Health departments with mental disorders as the primary diagnosis • In the past year, 14% of Defiance County adults • 10.3% of physician visits with depression had a period of two or more weeks when they felt indicated on the medical record so worried, tense or anxious nearly every day that • 42,773 suicide deaths they stopped doing usual activities. • 13.4 suicide deaths per 100,000 population

(Source: CDC, National Center for Health Statistics, Mental Health, • Eleven percent (11%) of adults had a period of two Depression, updated 5/3/2017) or more weeks when they felt sad, blue or depressed nearly every day, increasing to 23% of those with incomes less than $25,000.

• Two percent (2%) of Defiance County adults considered attempting suicide in the past year.

• No adult reported attempting suicide in the past year.

• Adults indicated the following caused them anxiety, stress or depression: job stress (36%), financial stress (35%), death of close family member or friend (21%), poverty/no money (18%), fighting at home (16%), sick family member (15%), other stress at home (14%), marital/dating relationship (7%), caring for a parent (5%), unemployment (5%), family member with mental illness (5%), divorce/separation (1%), not having a place to live (1%), sexual orientation/gender identity (1%), not feeling safe in the community (1%), not feeling safe at home (<1%), not having enough to eat (<1%), and other causes (12%).

• Defiance County adults dealt with stress in the following ways: prayer/meditation (42%), talked to someone they trust (39%), listened to music (25%), ate more or less than normal (24%), worked on a hobby (24%), exercised (23%), slept (22%), worked (18%), drank alcohol (13%), smoked tobacco (10%), took it out on others (5%), used prescription drugs as prescribed (3%), called a professional (2%), used illegal drugs (1%), misused prescription drugs (1%), and other ways (13%).

• Eleven percent (11%) of Defiance County adults had used a program or service to help with depression, anxiety, or other emotional problems for themselves or a loved one. Reasons for not using a program or service to help with depression, anxiety, or emotional problems included the following: had not thought of it (9%), could not afford to go (5%), stigma of seeking mental health services (4%), co-pay/deductible was too high (4%), other priorities (3%), did not know how to find a program (2%), fear (1%), and other reasons (5%). Eighty percent (80%) indicated this type of program was not needed.

• Adults reported they or a family member had been diagnosed with, or treated for, the following mental health issues: depression (39%), anxiety disorder (26%), anxiety or emotional problem (25%), attention deficit disorder (18%), bipolar (14%), alcohol and/or illicit drug abuse (14%), post-traumatic stress disorder (9%), autism spectrum (6%), psychotic disorder (6%), developmental disability (5%), life adjustment disorder (1%), and another mental health disorder (4%). One-fifth (20%) of adults indicated they or a family member had taken medication for a mental health issue.

• Defiance County adults received the social and emotional support they needed from the following: family (68%), friends (57%), God/prayer (42%), church (28%), neighbors (6%), internet (5%), a professional (5%), community (5%), online support group (1%), self-help group (1%), and other (3%). Six percent (6%) of adults reported they did not get the social and emotional support they need and 26% reported they do not need support/can handle it themselves.

ADULT MENTAL HEALTH | 71 The following graph shows Defiance County adults who felt sad or hopeless for two or more weeks in a row in the past year. Examples of how to interpret the information include: 11% of all Defiance County adults felt sad or hopeless for two or more weeks in a row, including 10% of males, and 12% of females.

Defiance County Adults Feeling Sad or Hopeless for Two or More Weeks in a Row 30%

25% 23%

20% 16% 14% 15% 13% 12% 11% 11% 11% 10% 10% 8% 7%

Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

Defiance Defiance Defiance Defiance Ohio U.S. Adult Comparisons County County County County 2015 2015 2008 2012 2015 2018 Considered attempting suicide in the 3% 2% 4% 2% N/A N/A past year Felt sad or hopeless for two or more 11% 13% 16% 11% N/A N/A weeks in a row

N/A – Not Available

National Suicide Statistics

• 44,965 people in the U.S. died from suicide, and 1,124,125 people attempted suicide in the 2016. • An average of one person killed themselves every 11.7 minutes • Suicide is the 10th ranking cause of death in the U.S. • For every female death by suicide, there are 3.4 male deaths. • In 2016, there were 1,707 suicide deaths in Ohio. • The leading suicide methods included: — Firearm suicides (51.0%) — Suffocation/Hanging (25.9%) — Poisoning (14.9%) — Cutting/Piercing (1.9%) — Drowning (1.1%)

(Source: American Association of Suicidology, Facts & Statistics, 2016 retrieved March 2018)

ADULT MENTAL HEALTH | 72 The graphs below show Defiance County suicide counts by age group and year. The first graph shows:

• From 2013 to 2017, 44% of all Defiance County suicide deaths occurred in those ages 45-64 years old.

Defiance County Number of Suicide Deaths By Age Group 2013-2017* Total Deaths =27

7 6 6

4 3

15-24 25-34 35-44 45-54 55-64 65+

Defiance County Number of Suicide Deaths By Year 2013 -2017* Total Deaths =27

6 6

2013 2014 2015 2016 2017

*Data for 2017 is partial and incomplete and should be used with caution (Source: Ohio Public Health Data Warehouse 2013-2017, updated 6/12/18)

ADULT MENTAL HEALTH | 73 Chronic Disease: Cardiovascular Health

Key Findings Defiance County Leading Causes of Death Five percent (5%) of adults had survived a heart attack and 3% 2014-2016 had survived a stroke at some time in their life. Forty percent (40%) were obese, 36% had high blood pressure, 27% had high Total Deaths: 1,181 blood cholesterol, and 19% were current smokers, four known risk factors for heart disease and stroke. • Heart Disease (23% of all deaths) • Cancer (23%) Heart Disease and Stroke • Chronic Lower Respiratory Diseases (7%) • Accidents, Unintentional Injury (6%)

• Stroke (5%) • In 2018, 5% of Defiance County adults reported they had survived a heart attack or myocardial infarction, increasing to (Source: Ohio Public Health Data Warehouse, 2014-2016) 15% of those over the age of 65.

• Seventy-one percent (71%) of adults who had survived a Ohio heart attack received treatment as a result of their heart Leading Causes of Death attack. 2014-2016

• Five percent (5%) of Ohio and 4% of U.S. adults reported they Total Deaths: 352,105

had a heart attack or myocardial infarction in 2016 (Source: 2016 • Heart Disease (23% of all deaths) BRFSS). • Cancers (22%) • Three percent (3%) of Defiance County adults reported they • Chronic Lower Respiratory Diseases (6%) had survived a stroke, increasing to 8% of those over the age • Accidents, Unintentional Injuries (6%) of 65 and 8% of those with incomes less than $25,000. • Stroke (5%)

(Source: Ohio Public Health Data Warehouse, 2014-2016) • More than half (55%) of adults who had survived a stroke received treatment as a result of their stroke.

• Four percent (4%) of Ohio and 3% of U.S. adults reported having had a stroke in 2016 (Source: 2016 BRFSS).

• Six percent (6%) of adults reported a doctor, nurse, or other health professional diagnosed them with angina or coronary heart disease, increasing to 19% of those over the age of 65.

• Seventy-one percent (71%) of adults with angina or coronary heart disease received treatment for their angina or heart disease.

• Five percent (5%) of Ohio and 4% of U.S. adults reported having had angina or coronary heart disease in 2016 (Source: 2016 BRFSS).

High Blood Pressure (Hypertension)

• Thirty-six percent (36%) of adults had been diagnosed with high blood pressure. The 2015 BRFSS reports hypertension prevalence rates of 34% for Ohio and 31% for the U.S.

• Ninety-one percent (91%) of adults with high blood pressure received treatment for their high blood pressure.

• More than four-fifths (88%) of adults had their blood pressure checked within the past year.

• Defiance County adults diagnosed with high blood pressure were more likely to have: — Been ages 65 years or older (71%) — Been classified as obese by Body Mass Index-BMI (50%) — Incomes less than $25,000 (38%) — Rated their overall health as fair or poor (23%)

ADULT CARDIOVASCULAR HEALTH | 74 High Blood Cholesterol

• More than one-fourth (27%) of adults had been diagnosed with high blood cholesterol. The 2015 BRFSS reported that 37% of Ohio and 36% of U.S. adults have been told they have high blood cholesterol.

• Almost three-fourths (74%) of adults with high blood cholesterol received treatment for their high blood cholesterol.

• More than three-fourths (78%) of adults had their blood cholesterol checked within the past 5 years. The 2015 BRFSS reported 78% of Ohio and U.S. adults had their blood cholesterol checked within the past 5 years.

• Defiance County adults with high blood cholesterol were more likely to have: — Been ages 65 years or older (47%) — Been classified as obese by Body Mass Index-BMI (32%) — Incomes less than $25,000 (22%) — Rated their overall health as fair or poor (20%)

The following graph demonstrates the percentage of Defiance County adults who had major risk factors for developing cardiovascular disease (CVD).

Defiance County Adults with CVD Risk Factors 50%

40% 36%

27%

25% 23% 19%

13%

0% Obesity High Blood High Blood Sedentary Smoking Diabetes Pressure Cholesterol (Source: 2018 Defiance County Health Assessment)

Defiance Defiance Defiance Defiance Ohio U.S. Adult Comparisons County County County County 2016 2016 2008 2012 2015 2018 Had angina or coronary heart disease 2% 2% 1% 6% 5% 4% Had a heart attack 4% 5% 5% 5% 5% 4% Had a stroke 2% 2% 3% 3% 4% 3% Had been diagnosed with high blood 18% 34% 32% 36% 34%* 31%* pressure Had been diagnosed with high blood 18% 24% 27% 27% 37%* 36%* cholesterol Had blood cholesterol checked within past 76% 75% 70% 78% 78%* 78%* 5 years *2015 BRFSS data

ADULT CARDIOVASCULAR HEALTH | 75 The following graphs show the percentages of Defiance County adults who had been diagnosed with high blood pressure and high blood cholesterol. Examples of how to interpret the information on the first graph include: 36% of all Defiance County adults had been diagnosed with high blood pressure, including 39% of all Defiance County males and 71% of those 65 years and older.

Diagnosed with High Blood Pressure* 80%

71%

60%

39% 39% 38% 40% 36% 34% 34% 34% 32%

20% 18%

0% 0% Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

*Does not include respondents who indicated high blood pressure during pregnancy only.

Diagnosed with High Blood Cholesterol 60%

47%

40% 31% 29% 27% 27% 25% 23% 22% 24% 20% 18%

0% 0% Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

Note for graphs: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

ADULT CARDIOVASCULAR HEALTH | 76 The following graphs show the age-adjusted mortality rates per 100,000 population for heart disease and stroke.

• The Defiance County age-adjusted stroke mortality rate from 2014 to 2016 was slightly lower than the state rate and U.S. and slightly higher than the Healthy People 2020 target objective.

• From 2011 to 2016, the Defiance County male total age-adjusted heart disease mortality rate increased.

Age-Adjusted Heart Disease and Stroke Mortality Rates

300 250

188 200 175 169 150 101 100 40 50 36 37 34

population 100,000 per Rate 0 Heart Disease Stroke

Defiance 2014-2016 Ohio 2014-2016 U.S. 2014-2016 HP 2020 Target*

Note: The Healthy People 2020 Target objective for coronary heart disease is reported for heart attack mortality. (Sources: Ohio Public Health Data Warehouse, 2014-2016, CDC Wonder 2014-2016, Healthy People 2020)

Defiance County Age-Adjusted Heart Disease Mortality Rates by Gender

300

230 216 202 200 170 169 175

100 136 139 131 Rate per 100,000 population 100,000 per Rate 0 2008-2010 2011-2013 2014-2016 Defiance Total Defiance Male Defiance Female

(Source: Ohio Public Health Data Warehouse, 2008-2016)

ADULT CARDIOVASCULAR HEALTH | 77 The following graph shows the age-adjusted mortality rates per 100,000 population for stroke by gender.

• From 2014 to 2016, the Defiance County stroke mortality rate was significantly lower for females than for males.

Age-Adjusted Stroke Mortality Rates by Gender Age-Adjusted Stroke Mortality Rates by Gender

54 50 47 47 4748 4745 4847 43 42 41 36 35 32 35 27

population 100,000 per Rate population 100,000 per Rate

TotalTotal MaleMales FemaleFemales

DefianceAllen 2010-2011 2008-2010 AllenDefiance 2012-2013 2011-2013 AllenDefiance 2014-2015 2014-2016

(Source: Ohio Public Health Data Warehouse, 2008-2016)

Healthy People 2020 Objectives Heart Disease and Stroke

Defiance County 2015 Healthy People Objective Population U.S. Baseline 2020 Target Baseline 31% HDS-5: Reduce proportion of adults with 36% Adults age 18 and 27% hypertension (2018) up HDS-6: Increase proportion of adults who 78% 78% had their blood cholesterol checked within 82% (2018) Adults age 18 & up the preceding 5 years 36% HDS-7: Decrease proportion of adults with 27% Adults age 20+ with 14% high total blood cholesterol (TBC) (2018) TBC>240 mg/dl

Note: All U.S. figures age-adjusted to 2000 population standard. (Source: Healthy People 2020, 2015 BRFSS, 2018 Defiance County Health Assessment)

ADULT CARDIOVASCULAR HEALTH | 78

Chronic Disease: Cancer

Key Findings Defiance County Incidence of Cancer, 2011-2015 Nine percent (9%) of Defiance County adults had been All Types: 1,099 cases diagnosed with cancer at some time in their life. The Ohio Department of Health (ODH) indicates that from 2014-2016, • Lung and Bronchus: 163 cases (15%) cancers caused 23% (274 of 1,181 total deaths) of all • Prostate: 150 cases (14%) Defiance County resident deaths. • Breast: 142 cases (13%) • Colon and Rectum: 106 cases (10%) Adult Cancer In 2014-2016, there were 274 cancer deaths in • Nine percent (9%) Defiance County adults were Defiance County. diagnosed with cancer at some point in their lives, (Source: Ohio Cancer Incidence Surveillance System, Ohio Public increasing to 34% of those over the age of 65. Health Information Warehouse, 2011-2015)

• Of those diagnosed with cancer, they reported the following types: other skin cancer (31%), breast (29%), prostate (26%), melanoma (3%), rectal (3%), colon (3%), Non-Hodgkin’s lymphoma (3%), endometrial (3%), leukemia (3%), and other types of cancer (8%). One percent (1%) of adults reported multiple types of cancer.

9% of Defiance County adults had been diagnosed with cancer at some

time in their life.

Cancer Facts

• The Ohio Department of Health (ODH) indicates that from 2014-2016, cancers caused 23% (274 of 1,181 total deaths) of all Defiance County resident deaths. The largest percent (30%) of 2014-2016 cancer deaths were from lung and bronchial cancer (Source: Ohio Public Health Data Warehouse, 2014-2016).

• The American Cancer Society reports that smoking tobacco is associated with cancers of the mouth; lips; nasal cavity (nose) and sinuses; larynx (voice box); pharynx (throat); and esophagus (swallowing tube). Also, smoking has been associated with cancers of the lung; colon and rectum; stomach; pancreas; kidney; bladder; uterine; cervix; ovary (mucinous); and acute myeloid leukemia (blood and bone marrow) (Source: American Cancer Society, Facts & Figures 2018).

• The American Cancer Society states that about 609,640 Americans are expected to die of cancer in 2018. Cancer is the second leading cause of death in the U.S., exceeded only by heart disease. Nearly 1 of every 7 deaths is associated with cancer (Source: American Cancer Society, Facts & Figures 2018).

Lung Cancer

• In Defiance County, 22% of male adults were current smokers, and 46% had stopped smoking for one or more days in the past 12 months because they were trying to quit.

• Approximately 15% of female adults in Defiance County were current smokers, and 45% had stopped smoking for one or more days in the past 12 months because they were trying to quit.

• The Ohio Department of Heath reports that lung and bronchus cancer (n=43) was the leading cause of male cancer deaths from 2014-2016 in Defiance County. Cancer of the prostate (n=13) and kidney and renal pelvis cancers (n=9) caused male deaths during the same time (Source: Ohio Public Health Data Warehouse, 2014-2016)

• The Ohio Department of Heath reports that lung and bronchus cancer was the leading cause of female cancer deaths (n=38) in Defiance County from 2014-2016, followed by colon and rectum (n=19) and breast (n=13) cancers (Source: Ohio Public Health Data Warehouse, 2014-2016).

ADULT CANCER | 79

• According to the American Cancer Society, smoking causes 80% of lung cancer deaths in the U.S. Men and women who smoke are about 25 times more likely to develop lung cancer than nonsmokers (Source: American Cancer Society, Facts & Figures 2018).

Breast Cancer

• In 2018, 39% of Defiance County females reported having had a clinical breast examination in the past year.

• Almost half (48%) of Defiance County females over the age of 40 had a mammogram in the past year.

• The 5-year relative survival for women diagnosed with localized breast cancer (cancer that has not spread to lymph nodes or other locations outside the breast) is 99% (Source: American Cancer Society, Facts & Figures 2018).

• For women at average risk of breast cancer, recently updated American Cancer Society screening guidelines recommended that those 40 to 44 years of age have the choice of annual mammography, those 45 to 54 have an annual mammography, and those 55 years of age and older may transition to biennial or continue annual mammography. Women should continue mammography as long as their overall health is good and life expectancy is 10 or more years. For some women at high risk of breast cancer, annual screening using magnetic resonance imaging (MRI) in addition to mammography is recommended, typically starting at age 30 (Source: American Cancer Society, Facts & Figures 2018).

Prostate Cancer

• About two-fifths (41%) of Defiance County males had a Prostate-Specific Antigen (PSA) test at some time in their life, and 24% had one in the past year.

• Almost half (45%) of men had a digital rectal exam in their lifetime, and 10% had one in the past year.

• The ODH statistics indicate that prostate cancer deaths accounted for 10% of all male cancer deaths from 2014- 2016 in Defiance County (Source: Ohio Public Health Data Warehouse, 2014-2016).

• Incidence rates for prostate cancer are 74% higher in African Americans than in whites, and they are twice as likely to die of prostate cancer. Other risk factors include increased age, African ancestry, a family history of the disease and certain inherited genetic conditions. African American men and Caribbean men of African descent have the highest documented prostate cancer incidence rates in the world (Source: American Cancer Society, Facts & Figures 2018).

Colon and Rectum Cancers

• More than half (52%) of adults ages 50 and over had a colonoscopy or sigmoidoscopy in the past 5 years.

• ODH indicates that colon and rectum cancer deaths accounted for 9% of all male and female cancer deaths from 2014-2016 in Defiance County (Source: Ohio Public Health Data Warehouse, 2014-2016).

• The American Cancer Society reports several risk factors for colorectal cancer including age; personal or family history of colorectal cancer, polyps, or inflammatory bowel disease; obesity; physical inactivity; a diet high in red or processed meat; alcohol use; long-term smoking; and possibly very low intake of fruits and vegetables (Source: American Cancer Society, Facts & Figures 2018).

• In the U.S., 90% of colon cancers occur in individuals over the age of 50. Therefore, the American Cancer Society suggests every person over the age of 50 have regular colon cancer screening (Source: American Cancer Society, Facts & Figures 2018).

ADULT CANCER | 80

The following graph shows the Defiance County, Ohio and U.S. age-adjusted mortality rates (per 100,000 population, 2000 standard) for all types of cancer in comparison to the Healthy People 2020 objective, as well as cancer as a percent of total deaths in Defiance County. The graphs show:

• When age differences are accounted for, Defiance County had a higher mortality rate than Ohio and the U.S. The Defiance County age-adjusted cancer mortality rate was also higher than the Healthy People 2020 target objective.

• The percentage of Defiance County females who died from all cancers is slightly higher than the percentage of Defiance County males who died from all cancers.

Healthy People 2020 Objective and Age-AdjustedHealthy Mortality People 2020 Rates Objective for All Cancers 200 and183 Age-Adjusted Mortality Rates for All Cancers 250 175 180 161 161

160 201

140200 177 161 161 120 150 100

80 100 60 40 50 20 population 100,000 per Rate Rate per 100,000 population 100,000 per Rate 0 0 Defiance 2014-2016 Ohio 2014-2016 U.S. 2014-2016 HP 2020 Target Allen 2013-2015 Ohio 2013-2015 U.S. 2013-2015 HP 2020 Target

(Source: Ohio Public Health Data Warehouse 2014-2016, CDC Wonder 2014-2016, Healthy People 2020)

Cancer as a Percent of All Total Deaths in Defiance County by Gender, 2014-2016 14% 12% 12% 11%

10% 8%

4% 2%

0% Males Females

(Source: Ohio Public Health Data Warehouse, 2014-2016)

ADULT CANCER | 81

Defiance County Incidence of Cancer 2011-2015 Percent of Total Types of Cancer Number of Cases Incidence of Cancer

Lung and Bronchus 163 15%

Prostate 150 14%

Breast 142 13% Colon & Rectum 106 10%

Other Sites/Types 86 8%

Bladder 65 6%

Non-Hodgkins Lymphoma 51 5%

Uterus 46 4%

Kidney & Renal Pelvis 37 3% Melanoma of Skin 32 3%

Pancreas 31 3%

Leukemia 24 2%

Multiple Myeloma 22 2%

Oral Cavity & Pharynx 20 2%

Thyroid 19 2% Stomach 18 2%

Ovary 16 2%

Liver & Intrahepatic Bile Duct 14 1%

Brain and Other CNS 13 1%

Larynx 13 1%

Esophagus 11 1%

Hodgkins Lymphoma 9 <1% Testis 7 <1%

Cervix 4 <1%

Total 1,099 100%

(Source: Ohio Cancer Incidence Surveillance System, ODH Information Warehouse 2011-2015, Updated 2/2/2018)

2018 Cancer Estimates

• In 2018, about 1,735,350 million new cancer cases are expected to be diagnosed. • The World Cancer Research Fund estimates that about eighteen percent of the new cancer cases expected to occur in the U.S. in 2018 will be related to overweight or obesity, physical inactivity, and poor nutrition, and thus could be prevented. • About 609,640 Americans are expected to die of cancer in 2018. • Almost one third of cancer deaths are attributed to smoking. • In 2018, estimates predict that there will be 56,590 new cases of cancer and 25,740 cancer deaths in Ohio. • Of the new cancer cases, approximately 10,760 (16%) will be from lung and bronchus cancers and 5,550 (8%) will be from colon and rectum cancers. • About 10,610 new cases of female breast cancer are expected in Ohio. • New cases of male prostate cancer in Ohio are expected to be 5,810 (8%).

(Source: American Cancer Society, Facts and Figures 2018)

ADULT CANCER | 82

Chronic Disease: Asthma

Key Findings

In 2018, 14% of Defiance County adults had been diagnosed with asthma.

Asthma and Other Respiratory Disease

• Fourteen percent (14%) of Defiance County adults had been diagnosed with asthma, increasing to 24% of those with incomes less than $25,000.

• Fourteen percent (14%) of Ohio and 14% of U.S. adults had been diagnosed with asthma (Source: 2015 BRFSS).

• There are several important factors that may trigger an asthma attack. Some of these triggers are tobacco smoke; dust mites; outdoor air pollution; cockroach allergens; pets; mold; smoke from burning wood or grass; and infections linked to the flu, colds, and respiratory viruses (Source: CDC, Common Asthma Triggers, 2017).

• Chronic lower respiratory disease was the third leading cause of death in Defiance County and the third leading cause of death in Ohio from 2014 to 2016 (Source: Ohio Public Health Data Warehouse, 2014-2016).

40% Defiance County Adults Diagnosed with Asthma

30% 27% 24% 20% 20% 14% 12% 11% 11% 9% 10% 9% 6% 3%

0% Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

Defiance Defiance Defiance Defiance Ohio U.S. Adult Comparisons County County County County 2016 2016 2008 2012 2015 2018 Had been diagnosed with asthma 3% 12% 9% 14% 14% 14%

ADULT ASTHMA | 83

The following graphs demonstrate the lifetime and current prevalence rates of asthma by gender for Ohio residents.

Ohio Adult Lifetime Asthma Prevalence Rates By Gender

20% 15% 15% 13% Reported

- 10%

Percentage Self Percentage Males Females

Ohio Adult Current Asthma Prevalence Rates By Gender

12% 11%

10% 8%

Reported 8% -

2% Percentage Self Percentage 0% Males Females

(Source for graphs: 2016 BFRSS)

Asthma Facts

• The number of Americans with asthma grows every year. Currently, 26 million Americans have asthma. Of the 26 million, 18.9 million are adults.

• Almost 3,600 people die of asthma each year, nearly half of whom are age 65 or older.

• Asthma results in 439,000 hospitalizations and 1.8 million emergency room visits annually.

• Patients with asthma reported 14.2 million visits to a doctor’s office and 1.3 million visits to hospital outpatient departments.

• Effective asthma treatment includes monitoring the disease with a peak flow meter, identifying and avoiding allergen triggers, using drug therapies including bronchodilators and anti-inflammatory agents, and developing an emergency plan for severe attacks.

(Source: American College of Allergy, Asthma, & Immunology, Asthma Facts, 2016)

ADULT ASTHMA | 84 Chronic Disease: Diabetes

Key Findings Diabetes by the Numbers

In 2018, 13% of Defiance County adults had been • 30.3 million US adults have diabetes, and 1 in 4 of them don’t know they have it. diagnosed with diabetes. About two-fifths (38%) of adults with diabetes rated their health as fair or poor. • Diabetes is the seventh leading cause of death in the US. Diabetes • Diabetes I the No.1 cause of kidney failure,

lower -limb amputations, and adults-onset • Thirteen percent (13%) of Defiance County adults had blindness been diagnosed with diabetes, increasing to 28% of those over the age of 65. The 2016 BRFSS reports a • In the last 20 years, the number of adults prevalence of 11% for Ohio and the U.S. diagnosed with diabetes has more than tripled as the American population has aged and • About one-fourth (38%) of adults with diabetes rated become more overweight or obese.

their health as fair or poor. (Source: CDC, Diabetes by the Numbers, Updated: June 1, 2017)

• Ninety-two percent (92%) of adults with diabetes were receiving treatment for their diabetes.

• Defiance County adults diagnosed with diabetes also had one or more of the following characteristics or conditions: — 94% were obese or overweight — 77% had been diagnosed with high blood pressure — 59% had been diagnosed with high blood cholesterol

Defiance County Adults Diagnosed with Diabetes 40%

30% 28%

20% 15% 16% 13% 14% 12% 11% 12% 12% 9% 10%

0% 0% Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

Defiance Defiance Defiance Defiance Ohio U.S. Adult Comparisons County County County County 2016 2016 2008 2012 2015 2018 Had been diagnosed with 12% 12% 9% 13% 11% 11% diabetes

ADULT DIABETES | 85

Chronic Disease: Quality of Life

Key Findings

One-fifth (20%) of adults had fallen in the past 6 months. Eight percent (8%) of adults were responsible for providing regular care or assistant to an elderly parent or loved one.

Impairments and Health Problems

• Forty-seven percent (47%) of adults were limited in some way. Among those who were limited in some way, the following most limiting problems or impairments were reported: back or neck problems (47%); arthritis/rheumatism (34%); stress, depression, anxiety, or emotional problems (26%); walking problems (25%); chronic illness (24%); chronic pain (23%); fitness level (23%); lung/breathing problems (19%); sleep problems (18%); eye/vision problems (11%); hearing problems (11%); fractures, bone/joint injuries (10%); dental problems (8%); mental health illness/disorder (6%); learning disability (3%); substance dependency (1%); and other impairments/problems (5%).

• Defiance County adults were responsible for providing regular care or assistance to the following: multiple children (22%); an elderly parent or loved one (8%); a friend, family member or spouse with a health problem (7%); grandchildren (6%); an adult child (4%); children with discipline issues (3%); a friend, family member or spouse with a mental health issue (3%); someone with special needs (2%); a friend, family member or spouse with dementia (2%); and foster children (1%).

• Twenty percent (20%) of Defiance County adults had fallen in the past 6 months due to the following: same- level fall (slipping, tripping or stumbling) (40%), unexpected fall (28%), stairs (10%), ladders (5%), shower (2%), and some other way/place (11%).

Healthy People 2020 Arthritis, Osteoporosis, and Chronic Back Conditions (AOCBC)

Defiance Healthy People Objective County 2020 Target 2018 AOCBC-2: Reduce the proportion of adults with doctor- diagnosed arthritis who experience a limitation in activity 34% 36% due to arthritis or joint symptoms Note: U.S. baseline is age-adjusted to the 2000 population standard (Sources: Healthy People 2020 Objectives, 2018 Defiance County Health Assessment)

ADULT QUALITY OF LIFE | 86

The following graphs show the percentage of Defiance County adults who were limited in some way and the most limiting health problems. Examples of how to interpret the information shown on the first graph include: 47% of Defiance County adults were limited in some way, including 46% of males and 68% of those 65 and older.

Defiance County Adults Limited in Some Way 80% 68% 61% 60%

49% 47% 46% 46% 43% 39% 37% 40% 36%

25%

20%

Total Males Females Under 30 30-64 65 Years Income Income Defiance Defiance Defiance Years Years & Over <$25K >$25K 2008 2012 2015

Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

60% Defiance County Most Limiting Health Problems

50% 47%

40% 34%

30% 26% 25% 24%

20%

10%

0% Back or Neck Arthritis/Rheumatism Stress, Anxiety, Walking Problems Chronic Illness Problems Depression, Emotional Problems

ADULT QUALITY OF LIFE | 87 Social Conditions: Social Determinants of Health

Key Findings

Seven percent (7%) of Defiance County adults were abused in the past year (including physical, emotional, financial, or verbal abuse). In the past 12 months, 7% of Defiance County adults had to choose between paying bills and buying food. Ten percent (10%) of adults experienced 4 or more Adverse Childhood Experiences (ACEs) in their lifetime.

Healthy People 2020

Healthy People 2020 developed five key determinants as a “place-based” organizing framework. These five determinants include: — Economic stability — Education — Social and community context — Health and health care — Neighborhood and built environment

Economic Stability

• Defiance County adults attempted to get assistance from the following social service agencies: The Welfare Department/Job & Family Services (12%); food pantries (5%); friend or family member (4%); church/mosque/synagogue (3%); Raven, health department, St. Vincent DePaul, NOCAC (3%); Comprehensive Crisis Care/2-1-1 (1%); other charities (1%); Legal Aid (<1%); and somewhere else (2%). Two percent (2%) did not know where to look for assistance.

• Adults experienced the following food insecurity issues during the past 12 months: had to choose between paying bills and buying food (7%), food assistance was cut (4%), loss of income led to food insecurity issues (2%), worried food would run out (3%), were hungry but did not eat because they did not have money for food (1%), and went hungry/ate less to provide more food for their family (1%).

• Four percent (4%) of Defiance County adults experienced more than one food insecurity issue in the past year.

• The median household income in Defiance County in 2016 was $50,822. The U.S. Census Bureau reports median income levels of $50,674 for Ohio and $55,322 for the U.S. (Source: U.S. Census Bureau, Small Area Income and Poverty Estimates, 2016).

• Ten percent (10%) of all Defiance County residents were living in poverty, and 15% of children and youth ages 0-17 were living in poverty. (Source: U.S. Census Bureau, Small Area Income and Poverty Estimates, 2016).

• The unemployment rate for Defiance County civilian labor force was 4.1 as of April 2018 (Source: Ohio Department of Job and Family Services, Office of Workforce Development, Bureau of Labor Market Information).

• There were 16,712 housing units. The owner-occupied housing unit rate was 75%. Rent in Defiance County cost an average of $669 per month (Source: U.S. Census Bureau, American Community Survey, 2012-2016).

Education

• Ninety percent (90%) of Defiance County adults 25 years and over had a high school diploma. Ten percent (10%) had less than a high school diploma, compared to 11% for Ohio (Source: U.S. Census Bureau, American Community Survey, 2012-2016).

• Sixteen percent (16%) of Defiance County adults 25 years and over had a bachelor’s degree or higher (Source: U.S. Census Bureau, American Community Survey, 2012-2016).

ADULT SOCIAL DETERMINANTS OF HEALTH | 88 The map below shows the variation in poverty rates across Ohio during the 2012-16 period.

• The 2012 to 2016 American Community Survey 5-year estimates report that approximately 1,639,636 Ohio residents, or 14.5% of the population, were in poverty.

• From 2012 to 2016, almost 14% of Defiance County residents were in poverty.

Estimated Poverty Rates in Ohio by County (2012-2016)

(Source: 2012-2016 American Community Survey 5-year estimates, as compiled by Ohio Development Services Agency, Office of Research, Ohio Poverty Report, February 2018)

ADULT SOCIAL DETERMINANTS OF HEALTH | 89 Social and Community Context Social Determinants of Health

• Defiance County adults had the following • Social determinants of health are conditions in the transportation issues: other car issues/expenses environments in which people are born, live, learn, (3%), no car (3%), no public transportation work, play, worship, and age that affect a wide available or accessible (2%), no car insurance (1%), range of health, functioning, and quality-of-life suspended/no driver’s license (1%), limited public outcomes and risks. transportation available or accessible (1%), could • Conditions (e.g., social, economic, and physical) in not afford gas (1%), disabled (1%), and did not feel these various environments and settings (e.g., safe to drive (<1%). school, church, workplace, and neighborhood) have been referred to as “place.” In addition to the more • Seven percent (7%) of Defiance County adults material attributes of “place,” the patterns of social were abused in the past year. They were abused by engagement and sense of security and well-being the following: someone outside their home (52%), are also affected by where people live. a spouse or partner (28%), a child (21%), another • Resources that enhance quality of life can have a family member living in their household (10%), significant influence on population health and someone else (24%). outcomes. Examples of these resources include safe

and affordable housing, access to education, public • Four percent (4%) of Defiance County adults were safety, availability of healthy foods, local threatened with abuse in the past year. Those that emergency/health services, and environments free were abused were threatened to be abused by the of life-threatening toxins. following: someone outside their home (35%), a spouse or partner (24%), a child (6%), and • Understanding the relationship between how someone else (88%). population groups experience “place” and the impact of “place” on health is fundamental to the • Defiance County adults experienced the following social determinants of health—including both in the past 12 months: death of a family member social and physical determinants.

or close friend (60%); a close family member went (Source: HealthyPeople2020, Retrieved May 19, 2017) to the hospital (51%); moved to a new address (22%); had bills they could not pay (17%); someone close to them had a problem with drinking or drugs (12%); someone in their household lost their job/had their hours at work reduced (12%); had bills they could not pay (11%); someone homeless living with them (6%); household income was cut by 50% (5%); their family was at risk for losing their household (5%); knew someone living in a hotel (3%); became separated or divorced (3%); witnessed someone in their family being hit or slapped (2%), and were homeless (<1%).

• Defiance County adults experienced the following adverse childhood experiences (ACEs): lived with someone who was a problem drinker or alcoholic (19%); their parents became separated or were divorced (16%); a parent or adult in their home swore at, insulted, or put them down (15%); lived with someone who was depressed, mentally ill, or suicidal (11%); their parents or adults in their home slapped, hit, kicked, punched, or beat each other up (10%); a parent or adult in their home hit, beat, kicked, or physically hurt them (8%); someone at least 5 years older than them or an adult touched them sexually (8%); lived with someone who used illegal stress drugs, or who abused prescription medications (6%); their family did not look out for each other, feel close to each other, or support each other (5%); someone at least 5 years older than them or an adult tried to make them touch them sexually (4%); lived with someone who served time or was sentenced to serve time in prison, jail or other correctional facility (4%); someone at least 5 years older than them or an adult forced them to have sex (3%); they did not have enough to eat, had to wear dirty clothes, and had no one to protect them (3%); and their parents were not married (2%).

• Ten percent (10%) of adults experienced 4 or more ACEs.

ADULT SOCIAL DETERMINANTS OF HEALTH | 90 Behaviors of Defiance County Adults Experienced 4 or More ACEs vs. Did Not Experience Any ACEs Experienced Did Not Adult Behaviors 4 or More Experience ACEs Any ACEs Classified as overweight or obese by BMI 85% 69% Current drinker (had at least one alcoholic beverage in the past 54% 52% month) Binge drinker (drank 5 or more drinks for males and 4 or more for 38% 50% females on an occasion) Current smoker (currently smoke on some or all days) 44% 15% Medication misuse in the past 6 months 13% 5% Contemplated suicide in the past 12 months 0% 1% Used recreational drugs in the past 6 months 10% 5%

Adverse Childhood Experiences (ACEs)

• Childhood abuse, neglect, and exposure to other traumatic stressors which we term adverse childhood experiences (ACE) are common. The most common are separated or divorced parents, verbal, physical or sexual abuse, witness of domestic violence, and having a family member with depression or mental illness.

• According to the CDC, 59% of people surveyed in five states in 2009 reported having had at least one ACE while 9% reported five or more ACEs.

• The short and long-term outcomes of these childhood exposures include a multitude of health and social problems such as: — Depression — Alcoholism and alcohol abuse Fetal death COPD — — — Illicit drug use — Unintended pregnancies

— Liver disease — Suicide attempts

— STDs — Early initiation of smoking — Multiple sexual partners — Risk for intimate partner violence

• Given the high prevalence of ACEs, additional efforts are needed at the state and local level to reduce and prevent childhood maltreatment and associated family dysfunction in the US.

• Studies are finding that there is a repetitive does-response relationship between ACE and levels of exposure. A dose-response means that as the dose of the stressor increases, the intensity of the outcome will increase as well. As the number of ACEs increase so does the risk for the following: — Myocardial Infarction — Asthma — Mental Distress — Disability — Unemployment — Stroke — Diabetes — Lowered educational attainment

(Source: Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System Survey ACE Data, 2009-2014. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2015)

ADULT SOCIAL DETERMINANTS OF HEALTH | 91 Health and Health Care

• In the past year, 12% of adults were uninsured, decreasing to 9% of those with incomes less than $25,000.

• See the Health Perceptions, Health Care Coverage, and Health Care Access sections for further health and health care information for Defiance County adults.

Neighborhood and Built Environment

• Defiance County adults lived in a single-family household (87%), a manufactured or modular home (5%), an apartment (4%), and a condominium/townhouse (4%).

• In the past year, 44% of adults reported their household income increased, 16% reported it decreased, and 41% of adults reported it stayed the same.

• Defiance County adults reported always wearing a helmet while riding the following: snowmobile (64%), motorcycle (23%), ATV (9%), and bike (9%).

• Defiance County adults reported never wearing a helmet while riding the following: bike (84%), ATV (66%), motorcycle (43%), and snowmobile (14%).

• Adults reported doing the following while driving: talking on hand-held cell phone (41%), eating (35%), talking on hands-free cell phone (25%), not wearing a seatbelt (18%), texting (13%), using internet on their cell phone (8%), being under the influence of alcohol (7%), reading (3%), being under the influence of prescription drugs (2%), being under the influence of recreational drugs (<1%), and other activities (such as applying makeup, shaving, etc.) (2%).

ADULT SOCIAL DETERMINANTS OF HEALTH | 92 Social Conditions: Environmental Health

Key Findings

Environmental Health

• Almost two-fifths (39%) of Defiance County adults used a septic tank for wastewater. Of those who had a septic tank, 33% had it pumped within the past 5 years, and 14% never had it pumped. Thirty-two percent (32%) did not know the last time their septic tank had been pumped.

• Thirty-nine percent (39%) of Defiance County adults had a private water source for drinking water. Of those who had a private water source, 10% had it tested within the past year, and 34% had never had it tested. More than one-fifth (22%) did not know the last time their water source had been tested.

Disaster Preparedness

• Defiance County households had the following disaster preparedness supplies: cell phone (86%), cell phone with texting (82%), working flashlight and working batteries (82%), working smoke detector (80%), computer/tablet (74%), 3-day supply of nonperishable food for everyone in the household (52%), 3-day supply of prescription medication for each person who takes prescribed medicines (50%), home land-line telephone (41%), working battery-operated radio and working batteries (39%), 3-day supply of water for everyone in the household (one gallon of water per person per day) (39%), communication plan (22%), generator (22%), and a disaster plan (10%).

• Adults indicated the following preferred ways of getting information from authorities in a large-scale disaster or emergency: television (74%), internet (66%), radio (65%), wireless emergency alerts (48%), text messages (43%), Facebook (43%), neighbors (30%), smart phone app (27%), print media (21%), landline phone (13%), other social media (12%), and Twitter (10%). Four percent (4%) of adults indicated they did not carry a cell phone on a regular basis, and 1% had disabled their wireless emergency alerts.

• Fifteen percent (15%) of adults reported their household was well prepared to handle a large-scale disaster or emergency, 51% felt somewhat prepared, and 29% felt not prepared at all.

ENVIRONMENTAL HEALTH | 93

Social Conditions: Parenting

Key Findings

In the past year, 52% of parents discussed dating and relationships with their 10-to18-year-old child.

Parenting

• Parents discussed the following topics with their 10- to 18-year-old child in the past year: dating and relationships (52%); weight status (48%); bullying (47%); negative effects of alcohol, tobacco, illegal drugs, or misusing prescription drugs (47%); career plan/post-secondary education (44%); volunteering (42%); social media issues (41%); body image (36%); school/legal consequences of using alcohol, tobacco, or other drugs (32%); refusal skills/peer pressure (31%); abstinence and how to refuse sex (31%); birth control, condoms, safer sex and STD prevention (27%); depression, anxiety, suicide (27%); and energy drinks (20%). Fourteen percent (14%) of parents reported they did not discuss any of these topics with their child in the past year.

How to Help Increase Your School-Aged Child's Social Ability

Consider the following as ways to foster your school-aged child's social abilities:

• Set and provide appropriate limits, guidelines, and expectations and consistently enforce using appropriate consequences. • Model appropriate behavior. • Offer compliments for your child being cooperative and for any personal achievements. • Help your child choose activities that are appropriate for your child's abilities. • Encourage your child to talk with you and be open with his or her feelings. • Encourage your child to read and read with your child. • Encourage your child to get involved with hobbies and other activities. • Encourage physical activity. • Encourage self-discipline; expect your child to follow rules that are set. • Teach your child to respect and listen to authority figures. • Encourage your child to talk about peer pressure and help set guidelines to deal with peer pressure. • Spend uninterrupted time together—giving full attention to your child. • Limit television, video, and computer time.

(Source: eClinicalWorks, The Growing Child: School Age (6 to 12 Years), 2018)

PARENTING| 94

Youth Health: Weight Status

Key Findings

Nearly one-fifth (19%) of Defiance County youth were obese, according to Body Mass Index (BMI) by age. When asked how they would describe their weight, 32% of youth reported that they were slightly or very overweight. Nearly three-quarters (71%) of youth exercised for 60 minutes on 3 or more days per week.

Youth Weight Status

• BMI for children is calculated differently from adults. The CDC uses BMI-for-age, which is gender and age specific, as children’s body fatness changes over the years as they grow. In children and teens, BMI is used to assess underweight, normal, overweight, and obese.

• Nearly one-fifth (19%) of Defiance County youth were classified as obese by Body Mass Index (BMI) calculations (YRBS 15% for the U.S. in 2017). Fourteen percent (14%) of youth were classified as overweight (2017 YRBS reported 16% for the U.S.). Sixty-four percent (64%) were normal weight, and 3% were underweight.

• Nearly one-third (32%) of youth described themselves as being either slightly or very overweight (2017 YRBS reported 32% for the U.S.).

• Forty-seven percent (47%) of all youth were trying to lose weight, increasing to 55% of females (compared to 38% of males) (2017 YRBS reported 47% for the U.S.).

19% of Defiance County youth were classified as obese.

• Youth did the following to lose weight or keep from gaining weight in the past 30 days: — Exercised (57%) — Drank more water (48%) — Ate more fruits and vegetables (33%) — Ate less food, fewer calories, or foods lower in fat (29%) — Skipped meals (15%) — Went without eating for 24 hours or more (6%) (2013 YRBS reported 13% for the U.S.) — Vomited or took laxatives (2%) (2013 YRBS reported 4% for the U.S.) — Smoked cigarettes (2%) — Took diet pills, powders, or liquids without a doctor’s advice (1%) (2013 YRBS reported 5% for the U.S.)

• One-third (33%) of youth did not do anything to lose or keep from gaining weight.

Nutrition

• In the past month, youth reported they went to bed hungry because there was not enough food in their home on the following occasions: sometimes (8%), most of the time (2%), and always (1%). Ninety percent (90%) of youth reported they rarely or never went to bed hungry.

• In a typical week, youth ate out at a restaurant or brought take-out food home to eat: 1 to 2 meals per week (58%); 3 to 4 meals per week (13%); and 5 or more meals per week (4%). One-fourth (25%) of youth did not eat out or bring takeout home to eat on any day in the past week.

• Four percent (4%) of youth ate 5 or more servings of fruit per day. Seventy percent (70%) ate 1 to 2 servings per day, and 21% ate 3 to 4 servings of fruit per day. Six percent (6%) of youth ate 0 servings of fruit per day.

• Four percent (4%) of youth ate 5 or more servings of vegetables per day. Sixty-nine percent (69%) ate 1 to 2 servings per day, and 14% ate 3 to 4 servings of vegetables per day. Thirteen percent (13%) of youth ate 0 servings of vegetables per day. YOUTH WEIGHT STATUS | 95

• More than half (53%) of youth had a sugar-sweetened beverage at least 1 to 2 times during the past week. Twenty-one percent (21%) had a sugar-sweetened beverage at least 3 to 4 times during the past week. Six perfect (6%) had a sugar-sweetened beverage 5 or more times during the past week. Twenty percent (20%) of youth did not drink any sugar-sweetened beverages in the past week.

• More than one-third (34%) of youth had a drink that was high in caffeine such as coffee, espresso or energy drinks at least 1 to 2 times during the past week. Ten percent (10%) had a drink that was high in caffeine at least 3 to 4 times during the past week. Three percent (3%) had a drink that was high in caffeine 5 or more times during the past week. Fifty-three percent (53%) of youth did not drink any highly caffeinated drinks in the past week.

Physical Activity

• Seventy-one percent (71%) of youth participated in at least 60 minutes of physical activity on 3 or more days in the past week. Fifty percent (50%) did so on 5 or more days in the past week (2017 YRBS reports 46% for the U.S.), and 26% did so every day in the past week (2017 YRBS reports 26% for the U.S.). Thirteen percent (13%) of youth did not participate in at least 60 minutes of physical activity on any day in the past week (2017 YRBS reports 15% for the U.S.).

• Over half (57%) of Defiance County youth participated in a sports or intramural program, and 47% of youth exercised outside of school.

• The CDC recommends that children and adolescents participate in at least 60 minutes of physical activity per day. As part of their 60 minutes a day, children should engage in aerobic activity, muscle strengthening, and bone strengthening, as appropriate to their age. Children should participate in each of these types of activity on at least three days per week.

• Defiance County youth spent an average of 3.5 hours on their cell phone, 1.9 hours on their computer/tablet, 1.4 hours watching TV and 1.2 hours playing non-active video games on an average day of the week.

• Sixteen percent (16%) of youth spent 3 or more hours watching TV on an average day (2017 YRBS reported 21% for the U.S.).

Defiance County youth did the following to lose weight in the past 30 Percent days:

Exercised 57% Drank more water 48%

Ate more fruits and vegetables 33%

Ate less food, fewer calories, or foods lower in fat 29% Skipped meals 15% Went without eating for 24 hours 6% Vomited or took laxatives 2%

Smoked cigarettes 2% Took diet pills, powders, or liquids without a doctor’s advice 1%

YOUTH WEIGHT STATUS | 96

The following graph shows the percentage of Defiance County youth who were classified as obese, overweight, normal weight or underweight according to Body Mass Index (BMI) by age. Examples of how to interpret the information in the graph include: 64% of all Defiance County youth were classified as normal weight, 19% were obese, 14% were overweight, and 3% were underweight for their age and gender.

Defiance County Youth BMI Classifications

3% 3% 2% 5% 3% 9% 5% 4% 100% 3%

80%

64% 64% 65% 65% 64% 62% 63% 59% 68% 60%

40%

14% 12% 14% 13% 16% 14% 14% 18% 20% 13%

21% 20% 19% 18% 19% 18% 14% 15% 18% 0%

Total Male Female 13 or 14 to 16 17 & Older Defiance Defiance Defiance Younger 2008 2012 2015

Obese Overweight Normal Weight Underweight

Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

Healthy People 2020 Nutrition and Weight Status (NWS)

Defiance U.S. Healthy People Objective County 2017 2020 Target 2018

NWS-10.4 Reduce the proportion 19% of children and adolescents aged 2 (6-12 Grade) 15% 15%* to 19 years who are considered 20% (9-12 Grade) obese (9-12 Grade)

*Note: The Healthy People 2020 target is for children and youth aged 2-19 years. (Sources: Healthy People 2020 Objectives, 2017 U.S. YRBS, 2018 Defiance County Health Assessment)

YOUTH WEIGHT STATUS | 97

Defiance Defiance Defiance Defiance Defiance U.S. County County County County County Youth Comparisons 2017 2008 2012 2015 2018 2018 (9th-12th) (6th-12th) (6th-12th) (6th-12th) (6th-12th) (9th-12th) Obese 14% 15% 18% 19% 20% 15% Overweight 18% 13% 16% 14% 13% 16% Described themselves as slightly 29% 29% 32% 32% 34% 32% or very overweight Trying to lose weight 45% 48% 46% 47% 49% 47% Exercised to lose weight (in the 50% 52% 49% 57% 58% N/A past 30 days) Ate less food, fewer calories, or foods lower in fat to lose weight 27% 34% 33% 29% 33% N/A (in the past 30 days) Went without eating for 24 hours 4% 7% 7% 6% 6% 13%* or more (in the past 30 days) Took diet pills, powders, or liquids without a doctor’s advice 1% 2% 2% 1% 1% 5%* (in the past 30 days) Vomited or took laxatives (in the 2% 2% 2% 2% 1% 4%* past 30 days) Physically active at least 60 minutes per day on every day in 31% 34% 31% 26% 31% 26% past week Physically active at least 60 minutes per day on 5 or more 53% 59% 55% 50% 55% 46% days in past week Did not participate in at least 60 minutes of physical activity on 11% 8% 11% 13% 14% 15% any day in past week Watched TV 3 or more hours per 36% 30% 23% 16% 15% 21% day (on an average school day) N/A – Not Available *Comparative YRBS data for U.S. is 2013

YOUTH WEIGHT STATUS | 98

Youth Health: Tobacco Use

Key Findings

Six percent (6%) of Defiance County youth were current smokers, increasing to 11% of those ages 17 and older. The average age of onset for smoking was 13.3 years old. Nine percent (9%) of youth used e-cigarettes in the past month.

Youth Tobacco Use Behaviors

• Fifteen percent (15%) of youth had tried cigarette smoking, increasing to 23% of those ages 17 and older (YRBS reported 29% for the U.S. in 2017).

• Four percent (4%) of all Defiance County youth had smoked a whole cigarette for the first time before the age of 13 (2015 YRBS reported 10% for the U.S. in 2017).

• One-fifth (20%) of those who had smoked a whole cigarette did so at 10 years old or younger, and another 13% had done so by 12 years old. The average age of onset for smoking was 13.3 years old.

• Six percent (6%) of Defiance County youth were current smokers, having smoked at some time in the past 30 days (YRBS reported 9% for the U.S. in 2017).

• Two percent (2%) of all Defiance County youth smoked cigarettes on 20 or more days during the past month (2017 YRBS reported 3% for the U.S).

• More than one-third (36%) of current smokers smoked cigarettes daily. 6% of Defiance County youth were current smokers, having smoked at some time in the past 30 days.

• Seventy-nine percent (79%) of Defiance County youth identified as current smokers were also current drinkers, defined as having had a drink of alcohol in the past 30 days.

• Nine percent (9%) of Defiance County youth used an electronic vapor product in the past 30 days, increasing to 23% of those ages 17 and older.

• Defiance County youth used the following forms of tobacco in the past year: e-cigarettes (9%), cigarettes (8%), flavored cigarettes (4%), Black & Milds (4%), Swisher Sweets (4%), cigars (4%), chewing tobacco or snuff (3%), cigarillos (2%), hookah (1%), other (1%), little cigars (1%), snus (<1%), and dissolvable tobacco products (<1%).

• More than half (56%) of Defiance County youth were exposed to second-hand smoke. Youth reported being exposed to second-hand smoke in the following places: another relative’s home (27%), home (25%), in the car (21%), at a friend’s home (18%), fairgrounds (13%) and the park/ball field (11%).

YOUTH TOBACCO USE | 99

The following graph shows the percentage of Defiance County youth who were current smokers (i.e. having smoked cigarettes in the past 30 days). Examples of how to interpret the information include: 6% of all Defiance County youth were current smokers, including 8% of males and 11% of those ages 17 and older.

20% Defiance County Youth Who Were Current Smokers

12% 11% 11%

10% 8% 8% 7% 6% 4%

0% Total Males Females 13 or 14 to 16 17 & Older Defiance Defiance Defiance Younger 2008 2012 2015

Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

9% of Defiance County youth used e-cigarettes in the past year.

The table below indicates correlations between current smokers and participating in risky behaviors, as well as other activities and experiences. An example of how to interpret the information includes: 84% of current smokers used marijuana in the past month, compared to 4% of non-current smokers.

Behaviors of Defiance County Youth Current Smokers vs. Non-Current Smokers Non- Youth Behaviors Current Current Smoker Smoker Currently participate in extracurricular activities 84% 92% Had at least one drink of alcohol (in the past 30 days) 79% 13% Have used marijuana (in the past 30 days) 63% 4% Had sexual intercourse (in their lifetime) 62% 17% Experienced 3 or more adverse childhood experiences (ACEs) (in their 44% 26% lifetime) Bullied (in the past 12 months) 40% 35% Misused medications (in their lifetime) 36% 3% Seriously considered attempting suicide (in the past 12 months) 36% 13% Attempted suicide (in the past 12 months) 36% 5%

*Current smokers are those youths surveyed who have self-reported smoking at any time during the past 30 days.

YOUTH TOBACCO USE | 100

Healthy People 2020 Tobacco Use (TU) Defiance Healthy U.S. Objective County People 2020 2017 2018 Target

6% 9% TU-2.2 Reduce use of cigarettes (6-12 Grade) (9-12 Grade) 16%* by adolescents (past month) 10% (9-12 Grade)

*Note: The Healthy People 2020 target is for youth in grades 9-12. (Sources: Healthy People 2020 Objectives, 2015 U.S. YRBSS, 2018 Defiance County Health Assessment)

Defiance Defiance Defiance Defiance Defiance U.S. County County County County County Youth Comparisons 2017 2008 2012 2015 2018 2018 (9th-12th) (6th-12th) (6th-12th) (6th-12th) (6th-12th) (9th-12th) Ever tried cigarette smoking 30% 31% 23% 15% 22% 29% (even one or two puffs) Current smokers (smoked on at 12% 11% 8% 6% 10% 9% least 1 day during the past 30 days) Smoked cigarettes on 20 or more days during the past month (of all 4% 2% 2% 1% 4% 3% youth) Smoked a whole cigarette for the first time before the age of 13 (of 11% 7% 4% 4% 6% 10% all youth)

E-Cigarette Use Among Youth and Young Adults

• E-cigarettes are now the most commonly used tobacco product among youth, surpassing conventional cigarettes in 2014.

• E-cigarette aerosol is not harmless “water vapor”. It can contain harmful and potentially harmful constituents, including nicotine. Nicotine exposure during adolescence can cause addiction and can harm the developing

adolescent brain.

• The most recent estimates available show that 13.5% of middle school students (2015), 37.7% of high school students (2015), and 35.8% of young adults (2013–2014) had ever used an e-cigarette.

• Among middle and high school students, both ever and past-30-day e-cigarette use have more than tripled since 2011.

• The most recent data available show that the prevalence of past-30-day use of e-cigarettes is similar among high school students (16% in 2015, 13.4% in 2014) and young adults 18–24 years of age (13.6% in 2013–2014) compared to middle school students (5.3% in 2015, 3.9% in 2014) and adults 25 years of age and older (5.7% in 2013–2014).

• In 2015, 58.8% of high school students who were current users of combustible tobacco products were also

current users of e-cigarettes.

• E-cigarette products can be used as a delivery system for cannabinoids and potentially for other illicit drugs. More specific surveillance measures are needed to assess the use of drugs other than nicotine in e-cigarettes.

(Source: U.S. Department of Health and Human Services, A Report of the Surgeon General, 2016)

YOUTH TOBACCO USE | 101

Youth Health: Alcohol Use

Key Findings

Youth Alcohol Consumption

• More than two-fifths (41%) of youth had at least one drink of alcohol in their life, increasing to 61% of those ages 17 and older (2017 YRBS reports 60% for the U.S.).

• Sixteen percent (16%) of youth had at least one drink in the past 30 days, increasing to 40% of those ages 17 and older (YRBS reports 30% for the U.S. in 2017).

• Based on all youth surveyed, 7% had five or more alcoholic drinks on occasion in the last month and would be considered binge drinkers by definition, increasing to 18% of those ages 17 and older (YRBS reports 14% for the U.S. in 2017). Of those who drank, 44% were considered binge drinkers, increasing to 53% of males.

• Thirty-six percent (36%) of youth who reported drinking at some time in their life had their first drink at 12 years old or younger, 28% took their first drink between the ages of 13 and 14, and 37% started drinking between the ages of 15 and 18. The average age of onset was 13.2 years old.

• Of all youth, 13% had drunk alcohol for the first time before the age of 13 (YRBS reports 16% for the U.S. in 2017).

In 2018, 16% of Defiance County youth had at least one drink

in the past 30 days.

• Youth drinkers reported they got their alcohol from the following: someone gave it to them (44%) [2017 YRBS reports 44% for the U.S.]; a parent gave it to them (41%); someone older bought it for them (28%); obtained it some other way (28%); an older friend or sibling bought it (15%); gave someone else money to buy it (15%); a friend’s parent gave it to them (11%); took it from a store or family member (6%); bought it at a restaurant, bar or club (1%); bought it with a fake ID (1%); and bought it in a liquor store/convenience store/gas station (1%).

• During the past month, 13% of all Defiance County youth had ridden in a car driven by someone who had been drinking alcohol (YRBS reports 17% for the U.S. in 2017).

• Three percent (3%) of youth drivers had driven a car in the past month after they had been drinking alcohol (YRBS reports 6% for the U.S. in 2017).

YOUTH ALCOHOL USE | 102

The following graphs show the percentage of Defiance County youth who drank in their lifetime and youth who were current drinkers. Examples of how to interpret the information include: 41% of all Defiance County youth had drank at some time in their life, including 40% of males and 61% of those 17 and older.

Defiance County Youth Who Had At least One Drink In Their Lifetime

100%

80% 61% 57% 60% 54% 50% 44% 41% 40% 41% 40% 23% 20%

Total Males Females 13 or 14 to 16 17 & Older Defiance Defiance Defiance Younger 2008 2012 2015

Defiance County Youth Who Were Current Drinkers 50%

40% 40%

30%

24%

19% 20% 20% 17% 16% 15% 15%

10%

0% Total Males Females 13 or 14 to 16 17 & Older Defiance Defiance Defiance

Younger 2008 2012 2015

Note for graphs: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

YOUTH ALCOHOL USE | 103

The following graph shows the percentage of youth who binge drank in the past month. Examples of how to interpret the information include: 7% of all Defiance County youth binge drank in the past month, including 8% of males and 18% of those 17 and older.

30% Defiance County Youth Binge Drinking in the Past Month

25%

20% 18%

15% 14%

10% 10%

10% 8% 7% 7% 6%

0% Total Males Females 13 or 14 to 16 17 & Older Defiance Defiance Defiance

Younger 2008 2012 2015

Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

Defiance Defiance Defiance Defiance Defiance U.S. County County County County County Youth Comparisons 2017 2008 2012 2015 2018 2018 (9th-12th) (6th-12th) (6th-12th) (6th-12th) (6th-12th) (9th-12th) Ever drank alcohol (at least one drink of alcohol on at least 1 day 54% 57% 50% 41% 55% 60% during their life) Current Drinker (at least one drink of alcohol on at least 1 day 19% 24% 20% 16% 27% 30% during the past 30 days) Binge drinker (drank 5 or more drinks within a couple of hours on 10% 14% 10% 7% 13% 14% at least 1 day during the past 30 days) Drank for the first time 23% 14% 16% 13% 11% 16% before age 13 (of all youth) Rode with a driver who had been drinking alcohol (in a car 18% 13% 13% 13% 12% 17% or other vehicle on 1 or more occasion during the past 30 days) Drank and drove (of youth 5% 3% 2% 3% 6% 6% drivers) Obtained the alcohol they drank by someone giving it to 62% 39% 24% 44% 46% 44% them (of youth drinkers)

YOUTH ALCOHOL USE | 104

The table below indicates correlations between current drinkers and participating in risky behaviors, as well as other activities and experiences. An example of how to interpret the information includes: 54% of current drinkers had sexual intercourse in their lifetime, compared to 12% of non-current drinkers.

Behaviors of Defiance County Youth

Current Drinkers vs. Non-Current Drinkers

Non- Current Youth Behaviors Current Drinker Drinker Currently participate in extracurricular activities 96% 90% Had sexual intercourse (in their lifetime) 54% 12% Experienced 3 or more adverse childhood experiences (ACEs) (in their lifetime) 45% 23% Bullied (in the past 12 months) 33% 36% Have used marijuana (in the past 30 days) 33% 2% Smoked cigarettes (in the past 30 days) 27% 1% Seriously considered attempting suicide (in the past 12 months) 25% 12% Misused medications (in their lifetime) 24% 1% Attempted suicide (in the past 12 months) 13% 6% “Current drinkers” indicate youth who self-reported having had at least one drink of alcohol during the past 30 days.

Healthy People 2020 Substance Abuse (SA) Defiance U.S. Healthy People Objective County 2017 2020 Target 2018 1% SA-14.4 Reduce the proportion (6-12 Grade) 14% of persons engaging in binge 9%* (9-12 Grade) drinking during the past month 13% (9-12 Grade)

*Note: The Healthy People 2020 target is for youth aged 12-17 years. (Sources: Healthy People 2020 Objectives, 2017 U.S. YRBS, 2018 Defiance County Health Assessment)

YOUTH ALCOHOL USE | 105

Youth Health: Drug Use

Key Findings

Youth Drug Use

• In 2018, 7% of all Defiance County youth had used marijuana at least once in the past 30 days, increasing to 17% of those over the age of 17. The 2017 YRBS found a prevalence of 21% for U.S. youth.

• Defiance County youth had tried the following in their life: — Inhalants (4%) (YRBS reports 6% for the U.S. in 2017) — Misused cough syrup (3%) — Posh/salvia/synthetic marijuana (3%) — Misused over-the-counter medications (2%) — Liquid THC (2%) — Bath salts (2%) — Steroids (2%) — Cocaine (1%) (YRBS reports 5% for U.S. in 2017) — Heroin (1%) (YRBS reports 2% for the U.S. in 2017) — Misused hand sanitizer (1%) — Ecstasy/MDMA/Molly (1%) (YRBS reports 4% for the U.S. in 2017) — Cloud 9 (1%) — Pharm party/skittles (1%) — Methamphetamines (<1%) (YRBS reports 3% for the U.S. in 2017) — GhB (<1%) — K2/spice (<1%)

• Five percent (5%) of youth used medications that were not prescribed for them or took more than prescribed to feel good or get high at some time in their lives, increasing to 11% of those ages 17 and older.

• Defiance County youth who misused prescription medications got them in the following ways: a friend gave it to them (41%), a parent gave it to them (27%), another family member gave it to them (18%), they took it from a friend or family member (18%), they bought it from a friend (14%), and they bought it from someone else (14%).

• Defiance County youth stated the following reasons for not seeking help to quit using alcohol, tobacco, or other drugs: do not know where to get help (25%), might get in trouble (23%), time (11%), trouble paying for it (7%), and transportation (1%). Sixty-one percent (61%) stated they do not think they need the help.

• Youth indicated the following reasons for not doing drugs: parents would be upset (67%), values (65%), legal consequences (54%), kicked out of extra-curricular activities (45%), health problems (43%), friends would not approve (36%), random student drug testing (19%), and other (29%).

• Youth indicated their biggest influencers for not doing alcohol, tobacco and/or drugs: parents (42%), peers (5%), law enforcement (3%), other adult (2%), teachers (1%), coaches (1%), religious leader (1%), siblings (1%), and other (7%).

YOUTH DRUG USE | 106

The following graphs indicate youth lifetime drug use and youth marijuana use in the past 30 days. Examples of how to interpret the information include: 5% of youth had misused medication at some point in their life, including 5% of males and 5% of females.

Defiance County Youth Lifetime Drug Use 15%

12%

10%

8% 7% 7%

5%5%5% 5% 5% 4% 4% 4% 3% 3% 2% 2%2% 2% 2% 2% 1% 1% 1% 1%1% 1% 1%

0% 0% 0% 0% 0%

Medications Steroids Inhalants Cocaine Heroin Meth

Total Male Female Defiance 2012 Defiance 2015

Defiance County Youth Marijuana Use in Past Month 30%

25%

20% 17%

15%

9% 10% 8% 8% 8% 7% 6% 6%

5% 2%

Total Males Females 13 or 14 to 16 17 & Older Defiance Defiance Defiance Younger 2008 2012 2015

Note for graphs: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

YOUTH DRUG USE | 107

Defiance Defiance Defiance Defiance Defiance U.S. County County County County County Youth Comparisons 2017 2008 2012 2015 2018 2018 (9th-12th) (6th-12th) (6th-12th) (6th-12th) (6th-12th) (9th-12th) Used marijuana in the past 8% 8% 9% 7% 12% 20% month Ever used methamphetamines 3% 1% <1% <1% 0% 3% (in their lifetime) Ever used cocaine (in their 2% 3% 2% 1% 2% 5% lifetime) Ever used heroin (in their 2% 1% 1% 1% 1% 2% lifetime) Ever took steroids without a doctor's prescription (in their 2% 4% 2% 2% 2% 3% lifetime) Ever used inhalants (in their 7% 8% 6% 4% 4% 6% lifetime) Ever used ecstasy (also called N/A 2% 2% 1% 1% 4% MDMA/Molly in their lifetime) Prescription medication 7% 12% 9% 5% 7% N/A abuse in the past month N/A – Not Available

The table below indicates correlations between current marijuana use and participating in risky behaviors, as well as other activities and experiences. An example of how to interpret the information includes: 52% of marijuana users smoked cigarettes in the past month, compared to 2% of non-marijuana users.

Behaviors of Defiance County Youth Current Marijuana Use vs. Non-Current Marijuana Use* Non- Current Current Youth Behavior Marijuana Marijuana User User Currently participate in extracurricular activities 100% 90% Have had at least one drink of alcohol (in the past 30 days) 76% 12% Had sexual intercourse (in their lifetime) 64% 16% Experienced 3 or more adverse childhood experiences (ACEs) (in their 60% 25% lifetime) Smoked cigarettes (in the past 30 days) 52% 2% Misused medications (in their lifetime) 43% 2% Bullied (in the past 12 months) 40% 35% Seriously considered attempting suicide (in the past 12 months) 33% 13% Attempted suicide (in the past 12 months) 24% 6%

*Current marijuana use indicates youth who self-reported using marijuana at any time during the past 30 days.

YOUTH DRUG USE | 108

Youth Health: Sexual Behavior

Key Findings

One-fifth (20%) of Defiance County youth had sexual intercourse in their lifetime. Sixteen percent (16%) of youth had participated in oral sex, and 3% had participated in anal sex. Seventeen percent (17%) of youth participated in sexting. Of those who were sexually active, 56% had multiple sexual partners.

Youth Sexual Behavior

• One-fifth (20%) of Defiance County youth have had sexual intercourse, increasing to 48% of those ages 17 and over (The YRBS reports 40% for U.S. in 2017).

• Sixteen percent (16%) of youth had participated in oral sex, increasing to 38% of those ages 17 and over.

• Three percent (3%) of youth had participated in anal sex, increasing to 7% of those ages 17 and over.

• Seventeen percent (17%) of youth had participated in sexting, increasing to 34% of those ages 17 and over.

• Almost one-fifth (17%) of youth had viewed pornography, increasing to 27% of males and 29% of those ages 17 and over.

20% of Defiance County youth have had sexual intercourse.

• Of sexually active youth, 44% had one sexual partner and 56% had multiple partners.

• Five percent (5%) of all Defiance County youth had 4 or more sexual partners (YRBS reports 10% for the U.S. in 2017).

• Of those youth who were sexually active, 12% had done so by the age of 13. Another 46% had done so by 15 years of age. The average age of onset was 15.1 years old.

• Of all youth, 2% were sexually active before the age of 13 (YRBS reports 3% for the U.S. in 2017).

• More than half (57%) of youth who were sexually active used condoms to prevent pregnancy; 37% used birth control pills; 17% used the withdrawal method; 11% used a shot, patch or birth control ring; 5% used some other method; and 2% used an IUD. One percent (1%) reported they were gay or lesbian. However, 10% engaged in sexual intercourse without a reliable method of protection, and 13% reported they were unsure.

• Of sexually active youth, 13% had drunk alcohol or used drugs before their last sexual encounter (YRBS reports 19% for the U.S. in 2017).

• In the past month, youth reported they experienced the following: received a text or an e-mail with a revealing, or sexual photo of someone (11%); texted, e-mailed, or posted electronically a revealing or sexual photo of themselves (6%); and a revealing or sexual photo of them was texted, emailed, or posted electronically without their permission (2%). Eighty-eight percent (88%) of youth reported none of these situations has applied to them in the past month.

YOUTH SEXUAL BEHAVIOR | 109

The following graphs show the percentage of Defiance County youth who participated in sexual intercourse and oral sex. Examples of how to interpret the information include: 20% of all Defiance County youth had sexual intercourse, including 22% of males, and 48% of those 17 and older.

75% Defiance County Youth Who Had Sexual Intercourse

48% 50%

28% 24% 23% 25% 22% 20% 18% 18%

0% 0% Total Males Females 13 or 14 to 16 17 & Older Defiance Defiance Defiance Younger 2008 2012 2015

10% of Defiance County youth who were sexually active were not using a reliable method of protection to prevent pregnancy.

50% Defiance County Youth Who Participated in Oral Sex

40% 38%

30% 28%

22% 20% 18% 16% 13% 14%

10%

0% 0% Total Males Females 13 or 14 to 16 17 & Older Defiance Defiance Younger 2012 2015

Note for graphs Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

YOUTH SEXUAL BEHAVIOR | 110

The following graphs show the percentage of Defiance County youth who participated in anal sex and sexting. Examples of how to interpret the information include: 3% of all Defiance County youth participated in anal sex, including 4% of males, and 7% of those 17 and older.

15% Defiance County Youth Who Participated in Anal Sex

10% 9% 7% 7%

5% 4% 3% 2% 2% 0% 0% Total Males Females 13 or 14 to 16 17 & Older Defiance Defiance Younger 2012 2015

Defiance County Youth Who Participated in Sexting 50%

40% 34% 30% 24% 22% 20% 20% 17% 17% 14%

10% 3% 0%

Total Males Females 13 or 14 to 16 17 & Older Defiance Defiance

Younger 2012 2015

Note for graphs: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

YOUTH SEXUAL BEHAVIOR | 111

Defiance Defiance Defiance Defiance Defiance U.S. County County County County County Youth Comparisons 2017 2008 2012* 2015 2018 2018 (9th-12th) (6th-12th) (6th-12th) (6th-12th) (6th-12th) (9th-12th) Ever had sexual intercourse 24% 28% 23% 20% 32% 40% Drank alcohol or used drugs 17% 18% 18% 13% 14% 19% before last sexual intercourse Used a condom (during last 66% 64% 61% 57% 62% 54% sexual intercourse Used birth control pills (during 28% 32% 24% 37% 38% 21% last sexual intercourse) Did not use any method to prevent pregnancy during last 19% 13% 13% 10% 11% 14% sexual intercourse Had sexual intercourse with four or more persons (of all 4% 5% 6% 5% 8% 10% youth during their life) Had sexual intercourse before the age 13 (for the first time of 4% 3% 3% 2% 4% 3% all youth) *Only students in grades 9th-12th were asked sexual health questions in 2012

Sexual Risk Behavior

• Many young people engage in sexual risk behaviors that can result in unintended health outcomes. For example, among U.S. high school students surveyed in 2015: — 41% had ever had sexual intercourse

— 30% had sexual intercourse during the previous 3 months. Of those who were sexually active in the past 3 months: 43% did not use a condom the last time they had sex, 14% did not use any method to prevent pregnancy, and 21% had drank alcohol or used drugs before last sexual intercourse. — Only 10% of sexually experienced students have ever been tested for HIV • Sexual risk behaviors place adolescents at risk for HIV infection, other sexually transmitted diseases (STDs), and unintended pregnancy. • Young people (aged 13-24) accounted for an estimated 21% of all new HIV diagnoses in the United States in 2016. • Among young people (aged 13-24) diagnosed with HIV in 2016, 81% were gay and bisexual males. • Half of the nearly 20 million new STDs reported each year are among young people, between the ages 15–24. • Nearly 210,000 babies were born to teen girls aged 15-19 years in 2016.

(Source: CDC, Adolescent and School Health, updated April 11, 2018)

YOUTH SEXUAL BEHAVIOR | 112

Youth Health: Mental Health

Key Findings

Fourteen percent (14%) of Defiance County youth had seriously considered attempting suicide in the past year, and 7% attempted suicide in the past year. Two-fifths (40%) of Defiance County youth reported academic success caused them anxiety, stress, or depression. More than one-fourth (27%) of youth had three or more adverse childhood experiences (ACEs).

Youth Mental Health

• More than one-quarter (28%) of youth reported they felt so sad or hopeless almost every day for two weeks or more in a row that they stopped doing some usual activities, increasing to 34% of females (YRBS reported 32% for the U.S. in 2017).

• Fourteen percent (14%) of youth reported they had seriously considered attempting suicide in the past 12 months, increasing to 20% of females. Fourteen percent (14%) of high school youth had seriously considered attempting suicide, compared to the 2017 YRBS rate of 17% for U.S. youth.

• In the past year, 7% of Defiance County youth had attempted suicide, increasing to 10% of females. Three percent (3%) of youth had made more than one attempt. The YRBS reported a suicide attempt prevalence rate of 7% for U.S. youth in 2017.

14% of youth reported they had seriously considered attempting suicide in the past 12 months.

• Almost three-fifths (59%) of youth reported they would be very likely or somewhat likely to seek help if they were dealing with depression or thoughts of suicide. Eighteen percent (18%) said they would be somewhat unlikely, and 24% said they would be very unlikely to seek help.

• Youth talked to the following when dealing with personal problems or feelings of depression or suicide: best friend (30%), parents (19%), girlfriend/boyfriend (14%), brother/sister (7%), adult relative (6%), adult friend (5%), caring adult (4%), school counselor (4%), professional counselor (4%), teacher (3%), youth minister (2%), pastor/priest (2%), call Teen Line or First Call for Help (1%), and other (3%). Fifteen percent (15%) of youth reported they talked to no one when dealing with personal problems or feelings of depression or suicide.

• Defiance County youth reported the following caused them anxiety, stress and depression: academic success (40%), self-image (33%), sports (30%), death of close family member or friend (30%), fighting with friends (30%), peer pressure (25%), other stress at home (23%), fighting at home (23%), dating relationship (19%), breakup (19%), parent divorce/separation (19%), being bullied (15%), caring for younger siblings (11%), poverty/no money (8%), parent is sick (8%), parent with a mental illness (5%), alcohol or drug use in the home (5%), not feeling safe at home (5%), sexual orientation (4%), not feeling safe in the community (4%), family member in military (4%), parent lost job (4%), not having enough to eat (4%), parent/caregiver with a substance abuse problem (3%), and not having a place to live (2%). More than one-fifth (22%) of youth stated none of the above caused them anxiety, stress, or depression.

• Defiance County youth reported the following ways of dealing with anxiety, stress, or depression: sleep (44%), hobbies (34%), text someone (29%), eat (28%), exercise (26%), talking to someone in their family (25%), pray (22%), talking to a peer (17%), using social media (14%), shop (10%), writing in a journal (9%), breaking something (9%), read the Bible (8%), self-harm (7%), talk to a counselor/teacher (7%), use medication that is prescribed for them (5%), drink alcohol (4%), smoke/use tobacco (4%), use illegal drugs (3%), talk to a medical professional (2%), vandalism or violent behavior (2%), use medication not prescribed to them (1%), harm someone else (1%), and gamble (1%). Twenty-four percent (24%) of youth reported they did not have anxiety, stress, or depression.

YOUTH MENTAL HEALTH | 113

• Youth reported the following reasons for not seeking help if they were dealing with anxiety, stress, depression or thoughts of suicide: can handle it themselves (32%), worried what others might think (23%), no time (16%), do not know where to go (13%), paying for it (11%), family would not support them in getting help (6%), transportation (5%), and friends would not support them in getting help (3%). Five percent (5%) reported they were currently in treatment.

• Youth reported the following adverse childhood experiences (ACEs): parents became separated or were divorced (35%); parents or adults in home swore at them, insulted them or put them down (27%); family did not look out for each other, feel close to each other, or support each other (19%); lived with someone who was depressed, mentally ill or suicidal (16%); lived with someone who was a problem drinker or alcoholic (15%); lived with someone who served time or was sentenced to serve in prison or jail (15%); lived with someone who used illegal street drugs or abused prescription drugs (13%); parents were not married (12%); parents or adults in the home abused each other (7%); did not have enough to eat, had to wear dirty clothes, and had no one to protect them (4%); parents or adults in home abused them (4%); someone 5 years older than them touched them sexually (3%); an adult or someone 5 years older than them tried to make them touch them sexually (3%), and an adult or someone 5 years older than them forced them to have sex (2%).

• More than one-fourth (27%) of youth experiences three or more ACEs.

The table below indicates correlations between those who experienced 3 or more ACEs in their lifetime and participating in risky behaviors, as well as other activities and experiences. An example of how to interpret the information includes: 31% of those who experienced 3 or more ACEs seriously considered attempting suicide, compared to 2% of those who did not experience any ACEs.

Behaviors of Defiance County Youth Experienced 3 or More ACEs vs. Did Not Experience Any ACEs

Did Not Experienced 3 Youth Behaviors Experience or More ACEs Any ACEs Currently participate in extracurricular activities 92% 90% Bullied (in the past 12 months) 49% 25% Had sexual intercourse (in their lifetime) 34% 13% Seriously considered attempting suicide (in the past 12 months) 31% 2% Have had at least one drink of alcohol (in the past 30 days) 27% 12% Have used marijuana (in the past 30 days) 16% 4% Attempted suicide (in the past 12 months) 15% 1% Smoked cigarettes (in the past 30 days) 10% 4%

YOUTH MENTAL HEALTH | 114

The following graphs show Defiance County youth who had seriously considered attempting suicide in the past year and youth who felt sad or hopeless every day for two weeks or more in a row. Examples of how to interpret the information include: 14% of youth seriously considered attempting suicide in the past year, including 8% of males and 20% of females.

Defiance County Youth Who Had Seriously Considered Attempting Suicide in 30% the Past 12 months

20% 20% 17%

15% 15% 14% 14% 11% 11%

10% 8%

0% Total Males Females 13 or 14 to 16 17 & Older Defiance Defiance Defiance Younger 2008 2012 2015

Defiance County Youth Who Felt Sad or Hopeless Almost Every Day for Two 50% Weeks or More in a Row Within the Past 12 Months

40% 34% 33% 29% 30% 28% 24% 25% 22% 22% 23%

20%

10%

0% Total Males Females 13 or 14 to 16 17 & Older Defiance Defiance Defiance Younger 2008 2012 2015

Note for graphs: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

YOUTH MENTAL HEALTH | 115

The following graph shows Defiance County youth who had attempted suicide in the past year. Examples of how to interpret the information include: 7% of youth attempted suicide in the past year, including 5% of males and 10% of females.

15% Defiance County Youth Who Attempted Suicide in the Past 12 Months

10% 10% 8% 8% 7% 7%

5% 5% 5% 5% 4%

0% Total Males Females 13 or 14 to 16 17 & Older Defiance Defiance Defiance

Younger 2008 2012 2015

Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

Defiance Defiance Defiance Defiance Defiance U.S. County County County County County Youth Comparisons 2017 2008 2012 2015 2018 2018 (9th-12th) (6th-12th) (6th-12th) (6th-12th) (6th-12th) (9th-12th) Seriously considered attempting suicide (in the past 11% 15% 15% 14% 14% 17% 12 months) Attempted suicide (in the past 7% 5% 5% 7% 6% 7% 12 months) Felt sad or hopeless (almost every day for 2 or more weeks in a row so that they stopped 22% 25% 23% 28% 32% 32% doing some usual activities in the past 12 months)

YOUTH MENTAL HEALTH | 116

The table below indicates correlations between those who contemplated suicide in the past 12 months and participating in risky behaviors, as well as other activities and experiences. An example of how to interpret the information includes: 68% of those who contemplated suicide were bullied in the past 12 months, compared to 29% of those who did not contemplate suicide.

Behaviors of Defiance County Youth Contemplated Suicide vs. Did Not Contemplate Suicide Did Not Contemplated Youth Behaviors Contemplate Suicide Suicide Bullied (in the past 12 months) 68% 29% Experienced 3 or more adverse childhood experiences (ACEs) 59% 22% (in their lifetime) Have had at least one drink of alcohol (in the past 30 days) 29% 14% Smoked cigarettes (in the past 30 days) 15% 4% Used marijuana (in the past 30 days) 18% 6%

“Contemplated suicide” indicates youth who self-reported seriously considering attempting suicide in the past year.

Youth Depression: Signs and Symptoms

• Occasionally being sad or feeling hopeless is a part of every child’s life. However, some children feel sad or uninterested in things that they used to enjoy, or feel helpless or hopeless in situations where they could do something to address the situations. When children feel persistent sadness and hopelessness, they may be

diagnosed with depression.

• Examples of behaviors often seen when children are depressed include — Feeling sad, hopeless, or irritable a lot of the time — Not wanting to do or enjoy doing fun things — Changes in eating patterns – eating a lot more or a lot less than usual — Changes in sleep patterns – sleeping a lot more or a lot less than normal — Changes in energy – being tired and sluggish or tense and restless a lot of the time — Having a hard time paying attention — Feeling worthless, useless, or guilty — Self-injury and self-destructive behavior

• Extreme depression can lead a child to think about suicide or plan for suicide. For youth ages 10-24 years, suicide is the leading form of death.

• Some children may not talk about helpless and hopeless thoughts, and they may not appear sad. Depression might also cause a child to make trouble or act unmotivated, so others might not notice that the child is depressed or may incorrectly label the child as a trouble-maker or lazy.

(Source: CDC, Children’s Mental Health: Anxiety and Depression, March 15, 2018)

YOUTH MENTAL HEALTH | 117

Youth Health: Social Determinants of Health

Key Findings

Personal Health

• Youth last saw a dentist for a check-up, exam, teeth cleaning, or other dental work at the following frequencies: less than a year ago (77%), (2015 YRBS reported 74% for the U.S.), 1 to 2 years ago (7%), more than 2 years ago (4%), never (1%), and do not know (10%).

• Defiance County youth had been told by a doctor or other health professional that they had: asthma (14%) (2017 YRBS reported 23% for the U.S.), needed to lose weight to improve their health (6%), high blood pressure (2%), diabetes (1%), and skin cancer (1%).

• Youth reported they felt they were putting their health at a greater risk by doing the following: drinking and driving (78%), smoking cigarettes (76%), riding in a car with someone who had been drinking alcohol (76%), texting while driving (75%), drinking alcohol (73%), bullying others (60%), carrying a weapon (52%), participating in other sexual activities (48%) and participating in sexual intercourse (47%).

Personal Safety

• In the past month, youth drivers did the following while driving: wore a seatbelt (86%), ate (59%), talked on their cell phone (57%), texted (43%), checked social media on cell phone (33%), used their cell phone other than for talking or texting (26%), applied makeup (8%), played electronic games (6%), drank alcohol (3%), used illegal drugs (2%), read (2%), and misused prescription drugs (1%).

• Sixty-nine percent (69%) of Defiance County youth said there are firearms in or around their home. Three percent (3%) reported they were unlocked and loaded.

• During the past 12 months, youth wore a helmet while riding a bike never (79%), rarely (11%), sometimes (5%), most of the time (3%), and always (3%).

• During the past 12 months, youth wore a helmet while riding an ATV never (47%), rarely (11%), sometimes (11%), most of the time (10%), and always (22%).

• During the past 12 months, youth wore a helmet while riding a snowmobile never (39%), rarely (3%), sometimes (7%), most of the time (5%), and always (46%).

• During the past 12 months, youth wore a helmet while riding a dirt bike/motorbike never (30%), rarely (5%), sometimes (3%), most of the time (10%), and always (52%).

• In the past year, 12% of youth suffered a blow or jolt to their head while playing with a sports team which caused them to get “knocked out,” have memory problems, get double or blurry vision, have headaches or “pressure” in the head, or experience nausea or vomiting, increasing to 17% of males.

• Sixty-seven percent (67%) of Defiance County youth reported that they had never heard of the choking game, also known as the pass-out game, space monkey, or dream game. Twenty percent (20%) have heard of the choking game, but don’t know anyone who has played it. Six percent (6%) have heard of it and know others who have played but have not played it themselves. Three percent (3%) have heard of it and was asked to play but refused. Two percent (2%) have played choking game once, and an additional two percent (2%) have played more than once. YOUTH SOCIAL DETERMINANTS OF HEALTH | 118

• Ninety-three percent (93%) of Defiance County youth had a social media or online gaming account.

• Of those who had an account, they reported the following: — My account is currently checked private (50%) — I know all of the people in “my friends” (50%) — I know all of the people I play with online (24%) — My parents have the password to these accounts (24%) — My friends have the password to some or all of these accounts (14%) — I share personal information about myself, such as where I live (10%) — I have been asked to share personal information about myself (13%) — I have been asked to meet someone I met online (8%) — I have been bullied as a result of these accounts (6%) — I have had problems as a result of these accounts (5%) — My parents do not know I have an account (4%) — I have participated in sexual activity with someone I met online (3%) — 7% of youth reported they did not have a social media account

• Over half (53%) of Defiance County youth who had a social media or online gaming account believed that sharing information online is dangerous.

• Defiance County youth reported living with the following individuals: both parents (57%), one parent (17%), mother and step-father (14%), father and step-mother (4%), mother and partner (3%), grandparents (2%), father and partner (1%), another relative (1%), guardians/foster parent (1%), and on their own or with friends (<1%).

• In the past year, youth reported they felt threatened or unsafe in their home at the following frequencies: 0 days (86%), 1 day (5%), 2 or 3 days (4%), 4 or 5 days (1%), and 6 or more days (4%).

• Ninety-one percent (91%) of youth participated in extracurricular activities. They participated in the following: school club or social organization (34%), church youth group (26%), caring for siblings after school (24%), church or religious organization (24%), part-time job (20%), babysitting for other kids (19%), volunteering in the community (15%), caring for parents or grandparents (3%), or some other organized activity (Scouts, 4H, etc.) (11%).

Defiance Defiance Defiance Defiance Defiance U.S. County County County County County Youth Comparisons 2015 2008 2012 2015 2018 2018 (9th-12th) (6th-12th) (6th-12th) (6th-12th) (6th-12th) (9th-12th) Visited a dentist within the past year (for a check-up, exam, N/A 75% 76% 77% 80% 74%* teeth cleaning, or other dental work) Suffered a blow or jolt to their head while playing with a N/A N/A 18% 12% 12% N/A sports team in the past year Ever been told by a doctor or health professional they had 20% 20% 18% 14% 15% 23% asthma N/A- Not Available *Comparative YRBS data for U.S. is 2015

YOUTH SOCIAL DETERMINANTS OF HEALTH | 119

Youth Health: Violence

Key Findings

Violence-Related Behaviors

• Nine percent (9%) of youth carried a weapon (such as a gun, knife or club) in the past 30 days, increasing to 17% of males. The YRBS reported 16% for the U.S. in 2017.

• In the past month, eleven percent (11%) of youth did not go to school on one or more days because they did not feel safe at school or on their way to or from school (YRBS reported 6% for the U.S. in 2017).

Physical and Sexual Violence

• In the past 12 months, 23% of youth had been involved in a physical fight, increasing to 35% of males. Eleven percent (11%) had been in a fight on more than one occasion (YRBS reported 24% for the U.S. in 2017).

• In the past year, 8% of youth reported an adult or caregiver had ever hit, slapped or physically hurt them on purpose.

• Four percent (4%) of youth reported a boyfriend or girlfriend hit, slapped, or physically hurt them on purpose in the past 12 months (2017 YRBS reported 8% for the U.S.).

• In their lifetime, Defiance County youth were forced to do the following: touched in an inappropriate sexual way (6%), sexual intercourse (2%), oral sex (2%), and other sexual activity (2%). Ninety-two percent (92%) of youth reported none of the above happened to them in their lifetime.

• In the past year, 14% of youth purposely hurt themselves without wanting to die, such as cutting or burning, increasing to 18% of females. Twelve percent (12%) had purposely hurt themselves on more than one occasion.

Bullying

• Almost two-fifths (36%) of youth had been bullied in the past year. The following types of bullying were reported: — 28% were verbally bullied (teased, taunted or called harmful names) — 22% were indirectly bullied (spread mean rumors about them or kept them out of a “group”) — 10% were cyber bullied (teased, taunted or threatened by e-mail or cell phone) (YRBS reported 15% for the U.S. in 2017) — 7% were physically bullied (were hit, kicked, punched or people took their belongings) — 5% were bullied on the school bus — 1% were sexually bullied (used nude or semi-nude pictures to pressure someone to have sex that did not want to, blackmail, intimidate, or exploit another person)

• More than two-fifths (44%) of those that had been bullied in the past year were bullied repeatedly by the same person.

• More than one-fourth (28%) of youth had been bullied on school property in the past year (YRBS reported 19% for the U.S. in 2017).

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The table below indicates correlations between those who were bullied in the past 12 months and participating in risky behaviors, as well as other activities and experiences. An example of how to interpret the information includes: 42% of those who were bullied felt sad or hopeless for two or more weeks in a row in the past year, compared to 20% of those who were not bullied.

Behaviors of Defiance County Youth Bullied vs. Non-Bullied Non- Youth Behavior Bullied Bullied Currently participate in extracurricular activities 89% 93% Felt sad or hopeless for two or more weeks in a row (in the past 42% 20% 12 months) Experienced 3 or more adverse childhood experiences (ACEs) 38% 22% (in their lifetime) Overweight or obese 29% 35% Seriously considered attempting suicide (in the past 12 months) 28% 7% Attempted suicide (in the past 12 months) 17% 2% Have had at least one drink of alcohol (in the past 30 days) 15% 17% Carried a weapon on school property (in the past 30 days) 10% 9% Used marijuana (in the past 30 days) 8% 7% Smoked cigarettes (in the past 30 days) 7% 5% Misused medications (in their lifetime) 4% 5%

Types of Bullying Defiance County Youth Experienced in Past Year

13 and 14-16 17 and Youth Behaviors Total Male Female younger Years old older

Verbally Bullied 28% 79% 68% 71% 70% 83%

Indirectly Bullied 22% 14% 29% 25% 20% 20%

Cyber Bullied 10% 7% 12% 13% 9% 7%

Physically Bullied 7% 5% 7% 7% 7% 4%

Sexually Bullied 1% 0% 1% 1% 1% 1%

Healthy People 2020 Injury and Violence Prevention (IVP) Defiance U.S. Healthy People Objective County 2017 2020 Target 2018 28% (6-12 Grade) IVP-35 Reduce bullying among 19% 18%* adolescents (9-12 Grade) 24% (9-12 Grade)

*Note: The Healthy People 2020 target is for youth in grades 9-12 who reported they were bullied on school property in the past year. (Sources: Healthy People 2020 Objectives, 2017 U.S. YRBS, 2018 Defiance County Health Assessment)

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The following graph shows Defiance County youth who did not go to school on one or more days in the past month because they felt unsafe. Examples of how to interpret the information include: 11% of youth did not go to school because they felt unsafe, including 8% of males and 13% of females.

Defiance County Youth Who Did Not Go to School in the Past Month on One or 20% More Days Because They Felt Unsafe

15% 13% 12% 11% 10% 10% 8%

6% 5% 4% 4% 4%

0% Total Males Females 13 & 14 to 16 17 & Older Defiance Defiance Defiance Younger 2008 2012 2015

Note: Caution should be used when interpreting subgroup results as the margin of error for any subgroup is higher than that of the overall survey.

Defiance Defiance Defiance Defiance Defiance U.S. County County County County County Youth Comparisons 2017 2008 2012 2015 2018 2018 (9th-12th) (6th-12th) (6th-12th) (6th-12th) (6th-12th) (9th-12th) Were in a physical fight (in the 27% 26% 26% 23% 21% 24% past 12 months) Carried a weapon (in the past 11% 13% 13% 9% 11% 16% 30 days) Did not go to school because they felt unsafe (at school or on 4% 4% 4% 11% 10% 6% their way to or from school in the past 30 days) Electronically bullied (in the 8% 15% 13% 10% 8% 15% past year) Bullied (in the past year) 51% 51% 49% 36% 31% N/A Were bullied on school property (during the past 12 N/A 36% 31% 28% 24% 19% months) Experienced physical dating violence (including being hit, slammed into something, or injured with an object or weapon 5% 6% 4% 4% 5% 8% on purpose by someone they were dating or going out with in the past 12 months) Ever physically forced to have 3% 7% 4% 2% 2% N/A sexual intercourse N/A- Not Available

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Child Health: Health and Functional Status

Key Findings 2016 National Survey of Children’s Health

In 2018, 40% of children were classified as obese by Body • 9% of Ohio children ages 0-5 were Mass Index (BMI) calculations. More than four-fifths (82%) of diagnosed with asthma, increasing to 16% of Defiance County parents had taken their child to the dentist 6-11 year olds. in the past year. Eleven percent (11%) of Defiance County • parents reported their child had been diagnosed with 13% of Ohio children ages 6-11 were diagnosed with ADD/ADHD. asthma. Seven percent (7%) of parents reported their child had been diagnosed with ADD/ADHD. (Source: National Survey of Children’s Health, 2016)

General Health Status

• In 2018, 95% of Defiance County parents rated their child’s health as excellent or very good. Four percent (4%) of parents rated their child’s health as fair, and <1% percent rated their child’s health as poor.

• Seven percent (7%) of children were born more than three weeks before their due date.

• Eighty-two percent (82%) of children had been to the dentist in the past year, decreasing to 55% of those with incomes less than $25,000.

• More than one-fourth (27%) of parents indicated their child did not get all the dental care they needed for the following reasons: child was not old enough to go/dentist would not see child yet because of their age (35%), cost (22%), could not find a dentist who accepted child’s insurance (19%), no insurance (15%), not available in area/transportation problems (7%), treatment is ongoing (6%), inconvenient times/could not get an appointment (4%), dissatisfaction with dentist (4%), no referral (3%), did not know where to go for treatment (3%), dissatisfaction with staff (1%), child refuses to go (1%), health plan problem (1%), and other reasons (15%).

• Nineteen percent (19%) of Defiance County children had difficulties in the following areas: emotions (11%), concentration (9%), behavior (7%), and being able to get along with people (4%).

• Parents reported their child’s difficulties were managed in the following ways: family and friends take care of it (64%), get professional help (45%), and school or day care (38%). Seventeen percent (17%) reported they do not need any help.

• In the past 12 months, 2% of parents reported their child had been poisoned by accident and required medical attention.

• In the past year, parents reported their child had been injured and required medical attention at the following frequencies: 1 time (11%), 2 times (4%), and 3 or more times (2%). Parents reported these injuries occurred in the following places: home (35%), school (13%), and some other place (39%). Thirteen percent (13%) of parents indicated injuries occurred at multiple places.

• More than two-fifths (44%) of parents reported their child had been tested for lead poisoning, and the results were within normal limits. Less than one percent (<1%) reported the levels were elevated, and medical follow- up was needed. One percent (1%) reported the levels were elevated, but no medical follow-up was needed. More than two-fifths (41%) of parents had not had their child tested for lead poisoning, and 13% of parents did not know if their child had been tested for lead.

• Defiance County parents did not apply for WIC for the following reasons: did not know if their child qualified (9%), inconvenient work schedule (2%), limited choices of brands/food (1%), too much paperwork/renewal every 6 months (1%), transportation (1%), and food stamps are easier to get and use (<1%).

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Weight Status and Nutrition

• Two-fifths (40%) of children were classified as obese by Body Mass Index (BMI) calculations. Twenty-nine percent (29%) of children were classified as overweight, 30% were normal weight, and 1% were underweight.

• Eighty-nine percent (89%) of parents reported their child was physically active for at least 60 minutes on 3 or more days per week. Two-thirds (66%) were physically active on 5 or more days, and 40% were physically active for at least 60 minutes every day per week. Two percent (1%) reported not engaging in any physical activity in the past week, and 1% were unable to be physically active.

• More than one-third (34%) of Defiance County children ate 5 or more servings of fruits and vegetables per day. Forty-eight percent (48%) ate 3 to 4 servings per day, 16% ate 1 to 2 servings of fruits and vegetables per day, and 2% ate 0 servings per day.

• Defiance County children ate breakfast at the following frequencies in the past week: 1 to 2 days (2%), 3 to 4 days (5%), and 5 or more days (93%).

• Defiance County children spent an average of 1.6 hours watching TV, 1.2 hours reading, 1.1 hours on a computer/tablet/cell phone, and 0.6 hours playing video games.

Health Conditions

• A doctor, health professional, or health educator told Defiance County parents their child had the following conditions:

— Asthma (11%) — ADD/ADHD (7%) — Speech and language delay (7%) — Developmental delay (5%) — Anxiety problems (4%) — Learning disability (4%) — Behavioral/conduct problems (3%) — Genetic or inherited condition (2%) — Epilepsy/seizure disorder (2%) — Intellectual disability or mental retardation (2%) — Autism or Autism Spectrum Disorder (ASD) (2%) — Brain injury, concussion or head injury (1%) — Cerebral palsy (1%) — Depression (<1%) — Eating disorders (<1%)

• Ten percent (10%) of Defiance County children ages 0-11 had at least one health condition.

• Parents reported their child had the following allergies: environmental allergies (13%), animal allergies (8%), milk (4%), red dye (2%), wheat (1%), eggs (1%), gluten (1%), other food allergies (1%), peanuts (<1%), bees (<1%), and other (5%). Of those with allergies, 2% had an Epi-pen.

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Defiance Defiance Defiance Defiance Ohio U.S. Ohio U.S. County County County County 2016 2016 2016 2016 Child Comparisons 2015 2018 2015 2018 Ages Ages Ages Ages Ages Ages Ages Ages 0-5 0-5 6-11 6-11 0-5 0-5 6-11 6-11 Rated health as excellent 94% 95% 94% 93% 92% 96% 91% 89% or very good Dental care visit in the 53% 52% 54%* 59%* 89% 85% 95% 91% past year Diagnosed with asthma 2% 9% 9% 6% 9% 12% 16% 15% Diagnosed with diabetes 0% 0% N/A N/A <1% 0% N/A <1% Diagnosed with 2% 1% 2%** 3%** 8% 9% 13% 9% ADHD/ADD Diagnosed with behavioral or conduct 0% 3% 3%** 5%** 3% 3% 13% 11% problems Diagnosed with epilepsy 0% 3% N/A 1% <1% 2% N/A 1% Diagnosed with a head injury, brain injury, or 1% 1% N/A 1% 1% 1% N/A 2% concussion Diagnosed with 0% 0% N/A N/A 2% 1% N/A 2% depression Children who were born premature (more than 3 N/A 9% 9% 11% N/A 7% 11% 12% weeks before their due date) Child had one or more N/A 9% 22% 22% N/A 10% 46% 42% health conditions N/A – Not available * Ages 1-5 ** Ages 3-5

Children’s Mental Health

• What are mental health disorders? — Mental health disorders among children are described as serious changes in the way children usually learn behave, or handle their emotions, which cause distress and problems getting through the day.

• What are the symptoms of mental disorders? — Symptoms may change over time as a child grows and may include difficulties with the way children play, learn, speak, and act or how the child handles their emotions. Diagnosis often occurs in the school years, however, some children with a disorder may not be recognized or diagnosed as having one.

• How are mental health disorders treated? — Childhood mental health disorders can be treated and managed. There are many treatment options based on the most current medical evidence and doctors should work closely with everyone involved in the child’s treatment (teachers, coaches, therapists, family members, etc.) — Early diagnosis and appropriate treatment can make a huge difference in the lives of children with mental health disorders.

(Source: Centers for Disease Control and Prevention, Children’s Mental Health, Updated March 2018)

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Asthma

The following graph shows the percentage of children who were diagnosed with asthma in Defiance County, Ohio, and the U.S.

• Defiance County had a lower percentage of children ages 6-11 who were diagnosed with asthma compared to both Ohio and the U.S.

20% Defiance County Children Diagnosed with Asthma 16% 15% 15% 12%

10% 9% 9% 6% 5%

0% Ages 0-5 Ages 6-11

Defiance County 2018 Ohio 2016 U.S. 2016

(Sources: National Survey of Children’s Health & 2018 Defiance County Health Assessment)

Asthma and Children

• Asthma is the most common chronic condition among children, currently affecting an estimated 6.1 million children under 18 years old, of which 3.5 million suffered from an asthma attack or episode in 2016. • An asthma episode is a series of events that results in constricted airways. These include swelling of the airway lining, tightening of the muscle around the airways and increased secretion of mucus inside the airway. This narrowed airway causes difficulty breathing with the familiar “wheeze.” • When a child has asthma, their lungs are extra sensitive to certain “triggers.” Each child reacts differently to the factors that may trigger asthma, including: — Excitement/stress — Indoor and outdoor air pollutants — Exposure to cold air or sudden temperature change — Allergic reactions to allergens such as pollen, dust, or mold — Respiratory infections and colds — Cigarette smoke • Secondhand smoke can cause serious harm to children. An estimated 400,000 to one million children with asthma have their condition worsened due to secondhand smoke. • Asthma can be life-threatening if not properly managed. In 2016, 169 children under 15 years old died from asthma. • Asthma is the third leading cause of hospitalization among children under the age of 15. • Asthma is one of the leading causes of school absenteeism. In 2013, asthma accounted for 13.8 million lost school days in school-aged children with an asthma episode in the previous year.

(Source: American Lung Association, Asthma & Children Fact Sheet, updated May 23, 2018)

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Child Health: Health Care Access

Key Findings 2016 National Survey of Children’s Health

In 2018, 5% of Defiance County parents reported their child • 28% of Ohio 0-5 year olds and 33% of Ohio did not currently have health insurance. Nearly one-fifth 6-11 year olds had public insurance. (19%) of parents reported their child did not get all of the • 91% of Ohio 0-5 year olds and 83% of Ohio prescription medications they needed in the past year. Over three-fourths (78%) of parents had taken their child to the 6-11 year olds had been to the doctor for preventive care in the past year. doctor for preventive care in the past year. (Source: National Survey of Children’s Health, 2016) Health Insurance

• Five percent (5%) of parents reported their child did not currently have health insurance.

• Defiance County children were covered by the following types of health insurance: parent’s employer (66%); Medicaid, Buckeye, Paramount, Molina, United, Care Source, or State Children’s Health Insurance Program (S- CHIP) (14%); purchased directly from an insurance company (2%); Insurance Marketplace (2%); TRICARE or other military health care (1%); Medicare (<1%); and some other source of insurance (2%).

• Parents reported their child’s health insurance covered the following: doctor visits (95%), prescription coverage (95%), well visits (95%), immunizations (94%), hospital stays (92%), dental (90%), vision (86%), mental health (73%), and therapies (speech, occupational therapy, physical therapy, etc.) (67%).

Medical Home

• Eighty-six percent (86%) of parents reported they had one or more people they think of as their child’s personal doctor or nurse, increasing to 92% of 0-5 year olds.

• More than three-fourths (78%) of children had visited their health care provider for preventive care in the past 12 months, increasing to 95% of 0-5 year olds.

• Ninety-seven percent (97%) of Defiance County parents reported that their child had one particular place they usually went if they were sick or needed advice about their health. They reported the following places: a private doctor’s office (81%), an urgent care center (11%), hospital emergency room (1%), a community health center (1%), and some other place (2%). Two percent (2%) reported multiple places including a private doctor’s office.

78% of Defiance County children visited their health care provider for preventive care in the past year.

• Parents reported using the emergency room (ER) for their child’s health care for the following reasons: serious illness/injury (52%), child could not get in to see primary care physician because of time of day/too long of a wait (20%), child’s doctor told them to go there (7%), child does not have a primary care physician (1%), and what they have always done/what they are used to (1%).

• Defiance County children have been referred and went to the following specialists: ear, nose, and throat (ENT) doctor (27%); pediatric ophthalmologist (eye doctor) (24%); allergist (10%); psychiatrist/mental health provider (6%); neurologist (6%); cardiologist (heart doctor) (5%); dermatologist (skin doctor) (5%); pulmonologist (lung doctor) (4%); developmental pediatrician (3%); endocrinologist (diabetes doctor) (3%); oncologist (cancer doctor) (1%); and other specialist (12%).

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Access and Utilization

• Nearly one-fifth (19%) of parents reported their child did not get all of the prescription medications they needed in the past year for the following reasons: their child was not prescribed medication (78%), cost (14%), health plan problem (4%), no insurance (2%), doctor did not know how to treat or provide care (2%), treatment is ongoing (2%), no referral (2%), could not find a doctor who accepted child’s insurance (1%), and other reasons (2%).

• Twelve percent (12%) of parents reported their child did not get all of the medical care they needed in the past year. They reported the following reasons: cost (48%), health plan problem (16%), no insurance (16%), not available in area/transportation problems (10%), treatment is ongoing (10%), dissatisfaction with doctor (6%), could not find a doctor who accepted child’s insurance (6%), dissatisfaction with office staff (3%), doctor did not know how to treat or provide care (3%), religious preference (3%), no referral (3%), and other reasons (19%).

• Six percent (6%) of Defiance County children received mental health treatment or counseling in the past year.

• Parents reported their child needed the following special services in the past year: speech therapy (6%), counseling (5%), medical equipment (3%), special education (3%), occupational therapy (2%), physical therapy (2%), out of home care (1%), psychiatry (1%). respite care (<1%), and home health nursing (<1%).

• Ninety percent (90%) of Defiance County children received all of their recommended vaccinations.

• Ten percent (10%) of children did not get all of their recommended vaccinations for the following reasons: child had received some, but not all, recommended vaccinations (50%); fear of negative effects (25%); parents chose to not vaccinate their child (21%); religious or cultural beliefs (18%); doctor advised against (11%); alternate vaccination schedule used (7%); and other reasons (14%).

• Of those parents who chose not to vaccinate their child, they did not get their child the following vaccines: influenza (100%), chickenpox (Varicella) (70%), hepatitis A (70%), hepatitis B (65%), Prevnar 13 (Pneumococcal Conjugate) (60%), MMR (measles, mumps, and rubella) (50%), HIB (Haemophilus) (50%), polio (40%), and DtaP/Tdap (diphtheria, tetanus, and pertussis) (35%).

Defiance Defiance Defiance Defiance Ohio U.S. Ohio U.S. County County County County 2016 2016 2016 2016 Child Comparisons 2015 2018 2015 2018 Ages Ages Ages Ages Ages Ages Ages Ages 0-5 0-5 6-11 6-11 0-5 0-5 6-11 6-11 Had public insurance 27% 27% 28% 37% 19% 9% 33% 38% Been to doctor for 86% 95% 91% 89% 64% 71% 83% 79% preventive care in past year Received all the medical care 88% 92% N/A N/A 89% 86% N/A N/A they needed Had a personal doctor or 80% 92% 75% 74% 74% 83% 77% 72% nurse Child received treatment or counseling from a mental N/A 1% 1%* 3% N/A 8% 10% 10% health professional in the past year N/A – Not available *3-5 years old

CHILD HEALTH CARE ACCESS | 128

(Source: Centers for Disease Control and Prevention, Immunization Schedules, 2018)

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Child Health: Early Childhood (Ages 0-5)

Key Findings

Early Childhood

The following information was reported by Defiance County parents of 0-5 year olds:

• During their last pregnancy, mothers did the following: took a prenatal vitamin with folic acid during pregnancy (92%), received prenatal care within the first 3 months (88%), took a prenatal vitamin with folic acid pre- pregnancy (72%), received a dental exam (57%), received WIC services (33%), took folic acid during pregnancy (31%), experienced depression during or after pregnancy (20%), took folic acid pre-pregnancy (18%), smoked cigarettes or other tobacco products (5%), consumed alcoholic beverages (2%), used e-cigarettes (3%), and used marijuana (2%). Five percent (5%) did none of these things.

• Thinking back to their last pregnancy, 44% of women wanted to be pregnant then, 21% wanted to be pregnant sooner, 14% did not want to be pregnant then or any time in the future, 8% wanted to be pregnant later, and 14% of women did not recall.

• When asked how parents put their child to sleep as an infant, 81% said on their back, 9% said in bed with themselves or another person, 7% said on their side, and 3% said on their stomach.

• Children were put to sleep in the following places: crib/bassinette without bumper, blankets, or stuffed animals (77%); pack n’ play (57%); swing (31%); car seat (29%); in bed with parent or another person (29%); crib/bassinette with bumper, blankets, or stuffed animals (16%); floor (9%); and a couch or chair (7%).

• Mothers breastfed their child less than 3 months (25%), 4 to 6 months (13%), 7 to 9 months (8%), 10 to 12 months (10%), more than one year (22%), still breastfeeding (3%), and never breastfed (19%).

• Parents reported looking for early childhood services or resources at the following locations: primary care physician/pediatrician (37%), Help Me Grow (21%), WIC (21%), library (9%), school website (9%), The Defiance County Family Services Guide (The Orange Book) (3%), and other (13%).

• Defiance County parents reported they read to their child at the following frequencies: a few times a week (33%), almost every day (24%), every day (35%), a few times a month (5%), and almost never because child had no interest (13%). No parent reported that they did not read to their child.

• Children 0-5 years old were more likely than children 6-11 years old to have: — Public insurance (27% compared to 9% of 6-11 years old). — Received all the medical care they needed (92% compared to 86% of 6-11 years old).

Defiance Defiance Ohio U.S. County County 2016 2016 2015 2018 Child Comparisons Ages Ages Ages Ages 0-5 0-5 0-5 0-5 Never breastfed their child 25% 19% 32% 21% Parent read to child every day 19% 35% 39% 38% Spent 4 or more hours watching TV 19% 9% 9% 9%

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Breastfeeding

The following graph shows the percent of infants who had been breastfed or given breast milk in Defiance County, Ohio, and U.S.

• Defiance County had a higher percent of children who had been breastfed for any length of time, compared to Ohio and the U.S.

Defiance County Children Breastfed 100%

81% 79% 80% 68%

60%

40% 32%

19% 21% 20%

0% Never Breastfed Breastfed

Defiance County Ohio 2016 U.S. 2016

(Sources: National Survey of Children’s Health & 2018 Defiance County Health Assessment)

Sleep-Related Infant Deaths: Who is at Greater Risk?

All infants are at risk for sleep-related deaths, but we know the risks are much greater for:

• Infants who bed share: 58% of sleep-related deaths occurred while the infant was sharing a sleep surface with another person. • Infants not placed to sleep on their backs: Only 36% of sleep-related deaths had been placed to sleep on their backs. • Infants not placed to sleep in a crib: 71% of sleep-related deaths occurred when infants were sleeping some place other than a crib or bassinet. 45% occurred in adult beds. • Infants exposed to tobacco smoke: 43% of sleep-related deaths were to infants exposed to tobacco smoke in utero and/or after birth. It is estimated that one-third of SIDS deaths would be prevented if maternal smoking during pregnancy were eliminated. • Younger infants: Sleep-related deaths decrease substantially after 3 months of age. 88% occurred prior to 6 months of age. • African-American infants: 38% of sleep-related deaths were African-American infants, which is disproportionately higher than their representation in the general infant population (15 percent). Differences in the prevalence of safe-sleep positioning and other environment conditions among races may contribute to this disparity.

(Source: ODH, Maternal and Child Health, Early Childhood, 2014, Sleep-Related Infant Deaths, 2017)

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Child Health: Middle Childhood (Ages 6-11)

Key Findings 2016 National Survey of Children’s Health

The following information was reported by Defiance • 9% of Ohio and 7% of U.S. parents of 6-11 year County parents of 6-11 year olds. Sixty-two percent olds reported their child watched 4 or more (62%) of parents felt their child was always safe at hours of TV or played video games each day.

school. More than two-fifths (45%) of parents reported • 82% of Ohio and 76% of U.S. parents of 6-11 year their child was bullied at some time in the past year. olds reported their child participated in one or Eighty-six percent (86%) of parents reported their child more organized activities outside of school. participated in extracurricular activities. (Source: National Survey of Children’s Health, 2016) Middle Childhood

The following information was reported by Defiance County parents of 6-11 year olds:

• Defiance County children were enrolled in the following types of schools: public (89%), private (8%), home- schooled (3%), and charter (1%). No parent reported their child was not enrolled in school.

• Parents reported their child missed school because of illness or injury at the following frequencies: 1 to 3 days (62%), 4 to 6 days (16%), 7 to 10 days (3%), and 11 or more days (2%).

• Defiance County children spent the following amount of time unsupervised after school on the average school day: no unsupervised time (77%), less than one hour (17%), 1 to 2 hours (5%), and more than 4 hours (1%).

• Eighty-six percent (86%) of children participated in extracurricular activities in the past year. They participated in the following: a sports team or sports lessons (83%); any type of volunteer work (44%); a club or organization after school or on weekends (40%); any other organized activities or lessons, such as music, dance, language, or other arts (34%); and any paid work (8%). Fourteen percent (14%) reported their child did not participate in any extracurricular activities in the past year.

• Seventeen percent (17%) of parents reported their child had a social media account or other virtual network account. Of those who had an account, they reported the following: they had their child’s password (82%), they knew all of the people in their child’s “friends” (74%), their child’s account was checked private (65%), and their child had a problem as a result of their account (3%). Three percent (3%) of parents reported they did not know if their child had a social network account.

45% of parents reported their child was bullied in the past year.

• Parents reported the extent in which they agreed that their child is safe in school. They reported the following: always (62%), usually (35%), and sometimes (3%). No parent reported their child was never safe in school.

• Forty-five percent (45%) of parents reported their child was bullied in the past year. The following types of bullying were reported: — 32% were verbally bullied (teased, taunted or called harmful names) — 17% were bullied on the school bus — 13% were physically bullied (they were hit, kicked, punched or people took their belongings) — 11% were indirectly bullied (spread mean rumors about them or kept out of a “group”) — 1% were cyber bullied (teased, taunted or threatened by e-mail or cell phone) — 0% were sexually bullied (using nude or semi-nude pictures to pressure someone to have sex that does not want to, blackmail, intimidate, or exploit another person)

• Four percent (4%) of parents reported they did not know if their child was bullied.

• Almost two-thirds (65%) of parents reported their child had been bullied repeatedly by the same person in the past year.

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• In the past month, Defiance County parents reported their child felt unhappy, sad, or depressed at the following frequencies: never (42%) and sometimes (58%). No parent reported their child was usually or always unhappy, sad, or depressed.

• Parents contacted the following agencies to help with problems they had with their child: child’s school (12%), mental health (5%), faith-based agency (2%), Board of Developmental Disabilities (2%), Bureau for Children with Medical Handicaps (2%), law enforcement (1%), juvenile court (1%), health department (1%), children’s services (1%), and legal services/legal aid (1%).

• Defiance County parents reported they were concerned a lot with the following issues with their 6-11 year old child: child’s academic achievement (10%); having enough time with their child (8%); their relationship with their child (8%); how their child cope with stressful things (7%); learning difficulties with their child (6%); their child’s self-esteem (5%); their child bullied by their classmates (4%); internet use (4%); cell phone and technology use (3%); their child’s anxiety (3%); their child getting along with others (2%); their child’s depression (1%); violence in home, school or neighborhood (1%); their child talking (1%); and eating disorders (1%)

• Children 6-11 years old were more likely than children 0-5 years old to have: — Attention deficit hyperactivity disorder (ADD) (9% compared to 1% of 0-5 years old). — Visited a dentist in the past year (85% compared to 52% of 0-5 years old).

Defiance Defiance Ohio U.S. County County Child Comparisons 2016 2016 2015 2018 6-11 Years 6-11 Years 6-11 Years 6-11 Years Child participated in one or more activities 85% 86% 82% 76% Child did not miss any days of school because of 27% 17% 26% 29% illness or injury Did not engage in any physical activity during the 1% 1% 3% 5% past week Parent felt child was usually/always safe at school 96% 96% 77% 79%

How to Help Increase Your School-Aged Child's Social Ability

• Consider the following as ways to foster your school-aged child's social abilities: — Set and provide appropriate limits, guidelines, and expectations and consistently enforce using appropriate consequences.

— Model appropriate behavior. — Offer compliments for your child being cooperative and for any personal achievements. — Help your child choose activities that are appropriate for your child's abilities. — Encourage your child to talk with you and be open with his or her feelings. — Encourage your child to read and read with your child. — Encourage your child to get involved with hobbies and other activities. — Encourage physical activity. — Encourage self-discipline; expect your child to follow rules that are set. — Teach your child to respect and listen to authority figures. — Encourage your child to talk about peer pressure and help set guidelines to deal with peer pressure. — Spend uninterrupted time together—giving full attention to your child. — Limit television, video, and computer time.

(Source: Stanford Children’s Health, The Growing Child: School Age (6 to 12 Years), 2017)

MIDDLE CHILDHOOD (AGES 6-11) | 133

Child Health: Family and Community Characteristics

Key Findings 2016 National Survey of Children’s Health

Thirteen percent (13%) of parents had at least one food • 51% of Ohio and 53% of U.S. parents of 0-5 insecurity issue in the past year. More than half (51%) of year olds reported their family ate a meal parents reported their child was always safe in their together every night of the week. neighborhood or community. Nine percent (9%) of children • 19% of 0-5 year old and 28% of 6-11 year old experienced 2 or more Adverse Childhood Experiences Ohio children lived in a household with (ACEs) in their lifetime. someone who smokes.

(Source: National Survey of Children’s Health, 2016) Family Functioning

• More than two-fifths (43%) of parents reported that every family member who lived in their household ate a meal together every day of the week, increasing to 49% of parents of 0-5 year olds. Families ate a meal together an average of 4.9 times per week.

• More than one-third (34%) of parents reported their child attended religious service 1 to 3 times per month, and 37% reported 4 or more times per month. Twenty-eight percent (28%) reported their child had never attended a religious service.

43% of Defiance County families ate a meal together every day of the week.

• Thirteen percent (13%) of parents had at least one food insecurity issue in the past year. They reported the following: had to choose between paying bills and buying food (7%), food assistance was cut (6%), loss of income led to food insecurity issues (3%), worried food would run out (3%), went hungry/ate less to provide more food for their family (3%), and were hungry but did not eat because they did not have money for food (1%).

• Parents reported their child got the following amounts of sleep on an average weeknight: 8 hours or less (25%), 9 hours (32%), 10 hours (30%), and 11 hours or more (13%).

• Parents used the following forms of discipline for their child: take away privileges (84%), time out (57%), grounding (42%), yell (40%), spanking (34%), wash mouth out (5%), and other (10%). Two percent (2%) of parents reported their child had not been disciplined.

Child Safety Characteristics

• Parents reported having the following safety items in their home: working smoke alarm/detector (95%), carbon monoxide detector (61%), fire extinguisher (58%), gun lock/safe (41%), Poison Control number by the phone (34%), and medication safe (19%). Ninety percent (90%) had more than one of these safety items in their home and 2% had none of these safety items in their home.

• More than half (53%) of parents reported they had a firearm in or around their home. One percent (1%) reported they were unlocked and loaded.

• Ninety-five percent (95%) of parents reported their child up to age five who met weight and/or height limits always rode in a car seat when a passenger in a car, 2% reported nearly always, and 2% reported their child sometimes rode in a car seat when a passenger in a car, and 2% reported their child never rode in a car seat when a passenger in the car.

PARENT HEALT FAMILY AND COMMUNITY CHARACTERISTICS | 134

• Fifty-nine percent (59%) of parents reported their child who weighs less than 80 pounds and is under 4’ 9” always rode in a booster seat, as compared to 22% who never rode in a booster seat.

• Three-fourths (75%) of parents whose child was old enough and/or tall enough to not be in a booster seat reported their child always wore a seat belt, and 12% reported their child never wore a seat belt.

• Parents reported their child always wore a helmet when riding the following: ATV (50%), skateboard (20%), bike (18%), and scooter (16%).

• Parents reported their child never wore a helmet when riding the following: scooter (44%), skateboard (37%), bike (34%), and an ATV (19%).

• Defiance County parents had the following rules about smoking in their home: no one is allowed to smoke inside their home at any time (78%), smoking is not allowed when children are present (5%), smoking is allowed anywhere (5%), and smoking is allowed in some rooms only (3%).

• Parents had the following rules about smoking in their car: no one is allowed to smoke inside their car at any time (80%), smoking is not allowed when children are present (9%), smoking is allowed as long as a window is open (4%), and smoking is allowed anywhere (1%).

Neighborhood and Community Characteristics

• Parents reported their child regularly attended an elementary school (69%); child care outside of their home provided by a relative other than a parent/guardian (27%); child care in their home provided by a relative other than a parent/guardian (21%); family-based child care outside of home (21%); nursery school, pre-school or kindergarten (19%); child care center (12%); child care in their home provided by a baby sitter (6%); and Head Start or Early Start program (2%).

• Defiance County parents reported their child experienced the following adverse childhood experiences (ACEs) in their lifetime: their parents became separated or were divorced (22%); lived with someone who was mentally ill or suicidal, or severely depressed for more than a couple of weeks (5%); lived with a parent/guardian who served time or was sentenced to serve time in prison or jail (5%); lived with someone who had a problem with alcohol or drugs (4%); seen or heard any parents or adults in their home hit, beat, kicked, or physically hurt each other (4%); been the victim of violence or witness violence in their neighborhood (3%), lived with a parent/guardian who died (2%); and were treated or judged unfairly because his/her ethnic group (1%).

• Nine percent (9%) of children experienced two or more ACEs in their lifetime, increasing to 18% of those with incomes less than $25,000.

• Parents reported their child was safe in their community or neighborhood always (51%), usually (40%), sometimes (9%), and never (<1%).

• Parents reported their neighborhood was unsafe due to the following concerns: heavy traffic area (15%), no sidewalks accessible (12%), drug/alcohol activity (6%), no place for kids to play (5%), loud/disrespectful noise levels (4%), crime (4%), bullying (3%), violence (2%), gangs (1%), and other (8%).

PARENT HEALT FAMILY AND COMMUNITY CHARACTERISTICS | 135

Family ate a meal together every day 50% 49% 51% 53% 40% 40% 43% 45% of the week Child experienced N/A 7% 18% 12% N/A 10% 29% 23% two or more ACEs Child never attends 5% 36% N/A N/A 12% 25% 22%* 18%* religious services Neighborhood is usually or always 96% 91% 88%* 86%* 95% 91% 86%* 86%* safe N/A – Not available *2011/2012 NSCH Data

Adverse Childhood Experiences (ACEs)

The following graph shows the percent of Defiance County, Ohio, and U.S. children who experienced two or more ACEs.

• Defiance County had a lower percent of children who experienced two or more ACEs as compared to Ohio and U.S children.

40% Defiance County Children Who Experienced 2+ ACEs

29% 30% 23%

20% 18%

12% 10% 10% 7%

Ages 0-5 Ages 6-11

Defiance County 2018 Ohio 2016 U.S. 2016

(Source: National Survey of Children’s Health & 2018 Defiance County Health Assessment)

PARENT HEALT FAMILY AND COMMUNITY CHARACTERISTICS | 136

Family Dinners

The following graph shows the percent of Defiance County, Ohio, and U.S. families that ate a meal together every day of the week.

• Forty-three percent (43%) of Defiance County families ate a meal together every day of the week.

100% Defiance County Families that Ate Together Everyday of the Week

80%

60% 43% 41% 43% 40%

20%

Defiance County 2018 Ohio 2016 U.S. 2016

(Source: National Survey of Children’s Health & 2018 Defiance County Health Assessment)

Five Ways That Family Meals Keep Kids Healthy

1. Family meals prevent excessive weight gain: Eating 3 or more family meals (meaning at least one parent is present and the meal is prepared at home) results in a 12% lower likelihood of children being overweight.

2. Family meals teach healthy food choices: The eating habits of childhood often last a lifetime. Families that ate at least three meals together each had a 20% decrease in unhealthy food choices. Teaching your children to enjoy healthy foods rather than junk foods is a gift that will stay with them through adulthood.

3. Family meals prevent eating disorders: Children and adolescents who ate family meals at least three times per week had a 35% reduction in disordered eating habits such as anorexia and bulimia.

4. Family dinner improves social-emotional health, too: The ability to understand emotions, express empathy, demonstrate self-regulation, and form positive relationships with peers and adults is called social-emotional health. Young children with high social-emotional health adapt well to the school environment and perform well academically, even in long term studies. Guess which kids had the best social-emotional health? The ones who ate family dinner together regularly and talked about their day, told stories, etc.

5. Family dinner can help kids deal with cyberbullying: About one-fifth of adolescents are victims of cyberbullying, putting them at risk for depression, substance abuse, and a host of other concerns. But adolescents who eat regular family dinners handle cyberbullying better and are less likely to engage in substance abuse or develop psychiatric health concerns, even after their involvement in face-to-face bullying is taken in to account.

(Source: The Benefits & Tricks to Having a Family Dinner, HealthyChildren.org, December 30, 2015)

PARENT HEALT FAMILY AND COMMUNITY CHARACTERISTICS | 137

Child Health: Parent Health

Key Findings

• Those filling out the survey had the following relationship to the child: mother (71%), father (26%), grandparent (3%), and other relative (<1%).

• Sixty-seven percent (67%) of parents rated their health as excellent or very good, decreasing to 46% of parents with incomes less than $25,000. More than one-fourth (27%) of parents rated their health as good, and 6% of parents rated their health as fair or poor.

• Almost three-fourths (73%) of parents rated their mental and emotional health as excellent or very good, decreasing to 51% of parents with incomes less than $25,000. Almost one-fourth (23%) rated their mental and emotional health as good, and 5% of parents rated their mental and emotional health as fair or poor.

• Two percent (2%) of mothers and 0% of fathers of 0-5 year olds rated their mental and emotional health as fair or poor. Six percent (6%) of mothers and 2% of fathers of 6-11 year olds rated their mental or emotional health as fair or poor.

• Eighty-five percent (85%) of parents reported having health care coverage, including health insurance, prepaid plans such as HMOs, or governmental plans such as Medicare. Fourteen percent (14%) reported not having any kind of health care coverage.

• Sixty-three percent (63%) of parents engaged in some type of physical activity or exercise for at least 30 minutes 3 or more days per week. Thirty-eight percent (38%) of parents exercised 5 or more days per week. Fourteen percent (14%) of parents did not participate in any physical activity in the past week.

• In the past year, 50% of parents missed work due to their child’s illnesses or injuries. Thirty-nine percent (39%) missed work due to their child’s medical appointments, 4% missed work due to lack of or unreliable child care, 6% missed work due to their child’s chronic illness, and 2% missed work due to their child’s behavioral/emotional problems.

• Parents reported the following challenges they face in regards to the day-to-day demands of parenthood/raising children: demands of multiple children (44%), working long hours (18%), financial burdens (17%), being a single parent (13%), managing child’s behavior (7%), difficulty with lifestyle changes (4%), child has special needs (4%), affordable housing (4%), mental health (3%), lack of parental support (3%), loss of freedom (3%), post-partum depression (1%), unemployment (1%), alcohol and/or drug abuse (1%), and lack of transportation (1%). Thirty-nine percent (39%) of parents reported no challenges associated with parenting.

• Seventy percent (70%) of parents felt they handle the day-to-day demands of raising children very well, and 30% reported somewhat well.

Defiance Defiance Defiance Defiance Ohio U.S. Ohio U.S. County County County County 2016 2016 2016 2016 Child Comparisons 2015 2018 2015 2018 Ages Ages Ages Ages Ages Ages Ages Ages 0-5 0-5 6-11 6-11 0-5 0-5 6-11 6-11 Mother’s mental or 1% 2% 5% 5% 5% 6% 9% 8% emotional health is fair/poor Father’s mental or emotional 11% 2% 5% 3% 2% 2% 6% 3% health is fair/poor

PARENT HEALTH | 138

Appendix I: Health Assessment Information Sources

Source Data Used Website

http://www.aacap.org/AACAP/Families_and American Academy of Child and _Youth/Facts_for_Families/FFF- Adolescent Psychiatry • Social Networking and Children Guide/Children-and-Social-Networking- 100.aspx http://www.suicidology.org/Portals/14/docs American Association of Suicidology • Suicide Facts /Resources/FactSheets/2016/2016datapgsv 1b.pdf?ver=2018-01-15-211057-387 https://www.cancer.org/content/dam/cance American Cancer Society, Cancer r-org/research/cancer-facts-and- Facts and Figures 2018. Atlanta: • 2018 Cancer Facts, Figures, and statistics/annual-cancer-facts-and- ACS, 2017 Estimates figures/2018/cancer-facts-and-figures- 2018.pdf American College of Allergy, Asthma http://acaai.org/news/facts- & Immunology • Asthma Facts statistics/asthma http://www.lung.org/lung-health-and- diseases/lung-disease- American Lung Association • Asthma and Children lookup/asthma/learn-about- asthma/asthma-children-facts-sheet.html Behavioral Risk Factor Surveillance System, National Center for Chronic Disease Prevention and Health • 2010 - 2015 Adult Ohio and U.S. https://www.cdc.gov/brfss/index.html Promotion, Behavioral Surveillance Correlating Statistics Branch, Centers for Disease Control https://www.cdc.gov/violenceprevention/ac CDC, Violence Prevention • Adverse Childhood Experiences (ACE) estudy/ CDC, Alcohol and Public Health • Excessive Drinking https://www.cdc.gov/alcohol/index.htm https://www.cdc.gov/childrensmentalhealth CDC, Children’s Mental Health • Anxiety and Depression /depression.html CDC, Asthma • Common Asthma Triggers https://www.cdc.gov/asthma/triggers.html https://www.cdc.gov/healthyweight/index.h CDC, Healthy Weight • Healthy Weight tml https://www.cdc.gov/physicalactivity/basics CDC, Physical Activity • Physical Activity for Everyone /index.htm https://www.cdc.gov/flu/about/season/flu- CDC, Seasonal Influenza • Who Should Get Vaccinated against Influenza season-2017-2018.htm https://www.cdc.gov/tobacco/data_statistic CDC, Smoking and Tobacco Use • Smoking and Other Health Risks s/fact_sheets/health_effects/effects_cig_sm oking/index.htm CDC, Division of Oral Health, National Center for Chronic Disease https://www.cdc.gov/oralhealth/index.html Prevention and Health Promotion, • Oral Health Basics 2015 https://www.cdc.gov/cancer/breast/basic_in CDC, Breast Cancer, 2016 • What Can I do to Reduce My Risk of Breast Cancer? fo/prevention.htm

• Sexual Risk Behavior https://www.cdc.gov/healthyyouth/sexualb CDC, Adolescent and School Health ehaviors/

APPENDIX I: INFORMATION SOURCES | 139

Source Data Used Website

https://www.cdc.gov/nchs/fastats/mens- CDC, Men’s Health • National Center for Health Statistics health.htm https://www.cdc.gov/nchs/fastats/depressio CDC, Mental Health • National Center for Health Statistics n.htm https://www.cdc.gov/oralhealth/basics/inde CDC, Oral Health • Oral Health Basics x.html www.cdc.gov/physicalactivity/everyone/gui CDC, Physical Activity for Everyone • Physical Activity Recommendations delines/adults.html https://www.cdc.gov/cancer/dcpc/resource CDC, Prostate Cancer • Prostate Cancer Awareness s/features/prostatecancer/index.htm https://www.cdc.gov/flu/protect/keyfacts.ht CDC, Seasonal Influenza (Flu), 2017 • Who Should Get a Yearly Flu Shot? m • Recommended Immunization https://www.cdc.gov/vaccines/schedules/d CDC, Recommended Immunization Schedule for Children and ownloads/child/0-18yrs-child-combined- Adolescents Aged 18 Years or schedule.pdf Younger https://www.cdc.gov/features/sexualviolenc CDC, Sexual Violence • Understanding Sexual Violence e/index.html • About Underlying Cause of Death, 2013-2015 CDC, Wonder • Defiance County and Ohio http://wonder.cdc.gov/ucd-icd10.html Leading Causes of Death • Defiance County and Ohio Mortality Statistics • Alcohol Beverage Expenditures • Bars and Drinking Community Commons Establishments www.communitycommons.org/ • Beer, Wine and Liquor Stores • Cigarette Expenditure http://www.countyhealthrankings.org/app/ County Health Rankings • USDA Food Environment Atlas ohio/2018/rankings/defiance/county/outco mes/overall/snapshot http://www.stanfordchildrens.org/en/topic/ default%3Fid%3Dthe-growing-child- school-age-6-to-12-years-90- eClinicalWorks • The Growing Child: School Age 6 to 12 Years P02278&sa=U&ei=eMq7VNe2I8_4yQSX- oCwAw&ved=0CEIQFjAI&usg=AFQjCNFn5t O-78ISMzUno4_7cO4dCvft1Q https://www.healthychildren.org/English/fa • The Benefits & Tricks to Having HealthyChilren.org mily-life/family-dynamics/Pages/Mealtime- a Family Dinner as-Family-Time.aspx • Access to Health Services • All Healthy People 2020 Target Healthy People 2020: U.S. Data Points www.healthypeople.gov/2020/topicsobjecti Department of Health & Human • Predictors of Access to Health ves2020 Services Care • Social Determinants of Health • Some U.S. Baseline Statistics

APPENDIX I: INFORMATION SOURCES | 140

Source Data Used Website

http://www.kff.org/report-section/the- uninsured-a-primer-2013-4-how-does- The Henry Kaiser Family Foundation • How Does Lack of Insurance Affect Access to Health Care? lack-of-insurance-affect-access-to-health- care/ https://teens.drugabuse.gov/drug- National Institute on Drug Abuse • Abuse of Prescription (Rx) for Teens facts/prescription-drugs National Survey of Children’s Health, • Children Who experience 2+ http://childhealthdata.org/docs/drc/apha- Data Resource Center ACEs aces-poster-final.pdf?Status=Master the Ohio Automated Rx Reporting • Ohio Automated Rx Reporting https://www.ohiopmp.gov/About.aspx System System (OAARS) http://healthtransformation.ohio.gov/LinkCl Office of Health Transformation • Ohio Medicaid Assessment ick.aspx?fileticket=oid6Wo- Survey y0gs%3D&tabid=160 • Defiance County and Ohio Birth http://www.odh.ohio.gov/healthstats/dataa Statistics ndstats.aspx https://www.odh.ohio.gov/health/cancer/oc • Incidence of Cancer isshs/newrpts1.aspx Ohio Department of Health, https://www.odh.ohio.gov/healthstats/vitals Information Warehouse • Leading Cause of Death tats/deathstat.aspx http://publicapps.odh.ohio.gov/EDW/DataB • Mortality rowser/Browse/Mortality https://www.odh.ohio.gov/en/odhprograms • STD Surveillance Data /stdsurv/std1 https://www.odh.ohio.gov/- ODH, Maternal and Child Health, /media/ODH/ASSETS/Files/data- Early Childhood • Sleep-Related Infant Deaths: statistics/maternal-and-child- Who is at Greater Risk? health/ec_Sleeprelatedinfant.pdf?la=en https://services.dps.ohio.gov/crashstatistics Ohio Department of Public Safety • 2017 Defiance County and Ohio Crash Facts /crashreports.aspx https://www.samhsa.gov/capt/practicing- Substance Abuse and Mental Health • Adverse Childhood Experiences effective-prevention/prevention- Services Administration (SAMHSA) (ACEs) behavioral-health/adverse-childhood- experiences • American Community Survey 5- https://www.census.gov/programs- year estimate, 2016 surveys/acs/ https://www.census.gov/data/tables/time- • Federal Poverty Threshold series/demo/income-poverty/historical- U. S. Department of Commerce, poverty-thresholds.html Census Bureau; Bureau of Economic Analysis • Ohio and Defiance County 2015 https://factfinder.census.gov/faces/nav/jsf/ Census Demographic pages/index.xhtml Information • Small Area Income and Poverty https://www.census.gov/programs- Estimates surveys/saipe.html U.S. Department of Health and • A Report of the Surgeon https://www.surgeongeneral.gov/library/re Human Services General ports/index.html Youth Risk Behavior Surveillance System, National Center for Chronic Disease Prevention and Health • 2009 - 2016 Youth Ohio and https://nccd.cdc.gov/youthonline/app/ Promotion, Division of Adolescent U.S. Correlating Statistics and School Health, Centers for Disease Control

APPENDIX I: INFORMATION SOURCES | 141

Appendix II: Acronyms and Terms

AHS Access to Health Services, Topic of Healthy People 2020 objectives Adult Defined as 19 years of age and older. Age-Adjusted Death rate per 100,000 adjusted for the age Mortality Rates distribution of the population. Adult Binge Drinking Consumption of five alcoholic beverages or more (for males) or four or more alcoholic beverages (for females) on one occasion. AOCBC Arthritis, Osteoporosis, and Chronic Back Conditions BMI Body Mass Index is defined as the contrasting measurement/relationship of weight to height. BRFSS Behavior Risk Factor Surveillance System, an adult survey conducted by the CDC. CDC Centers for Disease Control and Prevention. Current Smoker Individual who has smoked at least 100 cigarettes in their lifetime and now smokes daily or on some days. CY Calendar Year FY Fiscal Year HCNO Hospital Council of Northwest Ohio HDS Heart Disease and Stroke, Topic of Healthy People 2020 objectives HP 2020 Healthy People 2020, a comprehensive set of health objectives published by the Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services. Health Indicator A measure of the health of people in a community, such as cancer mortality rates, rates of obesity, or incidence of cigarette smoking. High Blood Cholesterol 240 mg/dL and above High Blood Pressure Systolic >140 and Diastolic > 90 IID Immunizations and Infectious Diseases, Topic of Healthy People 2020 objectives N/A Data is not available. NSCH National Survey of Children’s Health ODH Ohio Department of Health OSHP Ohio State Highway Patrol Race/Ethnicity Census 2010: U.S. Census data consider race and Hispanic origin separately. Census 2010 adhered to the standards of the Office of Management and Budget (OMB), which define Hispanic or Latino as “a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.” Data are presented as “Hispanic or Latino” and “Not Hispanic or Latino.” Census 2010 reported five race categories including: White, Black or African American, American Indian & Alaska Native, Asian, Native Hawaiian and Other Pacific Islander. Data reported, “White alone” or “Black alone”, means the respondents reported only one race. Ohio SHA/SHIP Ohio State Health Assessment/State Health Improvement Plan Weapon Defined in the YRBS as “a weapon such as a gun, knife, or club” Youth Defined as 12 through 18 years of age APPENDIX II: ACRONYMS AND TERMS | 142

YPLL/65 Years of Potential Life Lost before age 65. Indicator of premature death. Youth BMI Underweight is defined as BMI-for-age < 5th percentile Classifications Overweight is defined as BMI-for-age 85th percentile to < 95th percentile. Obese is defined as > 95th percentile.

YRBS Youth Risk Behavior Survey, a youth survey conducted by the CDC

APPENDIX II: ACRONYMS AND TERMS | 143

Appendix III: Methods for Weighting the 2017 Defiance County Health Assessment Data

Data from sample surveys have the potential for bias if there are different rates of response for different segments of the population. In other words, some subgroups of the population may be more represented in the completed surveys than they are in the population from which those surveys are sampled. If a sample has 25% of its respondents being male and 75% being female, then the sample is biased towards the views of females (if females respond differently than males). This same phenomenon holds true for any possible characteristic that may alter how an individual responds to the survey items.

In some cases, the procedures of the survey methods may purposefully over-sample a segment of the population to gain an appropriate number of responses from that subgroup for appropriate data analysis when investigating them separately (this is often done for minority groups). Whether the over-sampling is done inadvertently or purposefully, the data needs to be weighted so that the proportioned characteristics of the sample accurately reflect the proportioned characteristics of the population. In the 2017 Defiance County survey, a weighting was applied prior to the analysis that weighted the survey respondents to reflect the actual distribution of Defiance County based on age, sex, race, and income.

Weightings were created for each category within sex (male, female), race (White, Non-White), Age (8 different age categories), and income (9 different income categories). The numerical value of the weight for each category was calculated by taking the percent of Defiance County within the specific category and dividing that by the percent of the sample within that same specific category. Using sex as an example, the following represents the data from the 2017 Defiance County Survey and the 2016 Census estimates.

2017 Defiance Survey 2015 Census Estimate Weight Sex Number Percent Number Percent Male 241 56.44028 19,165 49.79474 0.882255 Female 186 43.55972 19,323 50.20526 1.152562

In this example, it shows that there was a larger portion of males in the sample compared to the actual portion in Defiance County. The weighting for females was calculated by taking the percent of females in Defiance County (based on Census information) (50.20526%) and dividing that by the percent found in the 2017 Defiance County sample (43.55972%) [50.20526/ 43.55972 = weighting of 1.152562 for females]. The same was done for males [49.79474/56.44028 = weighting of 0.882255 for males]. Thus males’ responses are weighted less by a factor of 0.882255 and females’ responses weighted heavier by a factor of 1.152562.

This same thing was done for each of the 21 specific categories as described above. For example, a respondent who was female, White, in the age category 35-44, and with a household income in the $50-$75k category would have an individual weighting of 2.59657 [1.15256 (weight for females) x 0.96818 (weight for White) x 1.92434 (weight for age 35-44) x 1.20920 (weight for income $50-$75k)]. Thus, each individual in the 2017 Defiance County sample has their own individual weighting based on their combination of age, race, sex, and income. See next page for each specific weighting and the numbers from which they were calculated.

Multiple sets of weightings were created and used in the statistical software package (SPSS 23.0) when calculating frequencies. For analyses done for the entire sample and analyses done based on subgroups other than age, race, sex, or income – the weightings that were calculated based on the product of the four weighting variables (age, race, sex, income) for everyone. When analyses were done comparing groups within one of the four weighting variables (e.g., smoking status by race/ethnicity), that specific variable was not used in the weighting score that was applied in the software package. In the example smoking status by race, the weighting score that was applied during analysis included only age, sex, and income. Thus a total of eight weighting scores for each individual were created and applied depending on the analysis conducted. The weight categories were as follows:

APPENDIX III: METHODS FOR WEIGHTING | 144

1. Total weight (product of 4 weights) – for all analyses that did not separate age, race, sex, or income. 2. Weight without sex (product of age, race, and income weights) – used when analyzing by sex. 3. Weight without age (product of sex, race, and income weights) – used when analyzing by age. 4. Weight without race (product of age, sex, and income weights) – used when analyzing by race. 5. Weight without income (product of age, race, and sex weights) – used when analyzing by income. 6. Weight without sex or age (product of race and income weights) – used when analyzing by sex and age. 7. Weight without sex or race (product of age and income weights) – used when analyzing by sex and race. 8. Weight without sex or income (product of age and race weights) – used when analyzing by sex and income.

Defiance Category % 2016 Census* % Weighting Value Sample

Sex: Male 241 56.44028 19,165 49.79474 0.882255 Female 186 43.55972 19,323 50.20526 1.152562

Age: 20-34 24 5.70071 6,801 24.03605 4.21632 35-44 36 8.55107 4,656 16.45520 1.92434 45-54 48 11.40143 4,932 17.43064 1.52881 55-59 34 8.07601 3,007 10.62732 1.31591 60-64 62 14.72684 2,447 8.64817 0.58724 65-74 125 29.69121 3,558 12.57466 0.42351 75-84 71 16.86461 2,090 7.38646 0.43799 65+ 21 4.98812 804 2.84149 0.56965

Race: White 382 89.88235 33,493 87.02193 0.96818 Non-White 43 10.11765 4,995 12.97807 1.28272

Household Income: Less than $10,000 14 3.71353 818 5.31929 1.43241 $10k-$15k 14 3.71353 767 4.98764 1.34310 $15k-$25k 61 16.18037 1,622 10.54754 0.65187 $25k-$35k 47 12.46684 1,968 12.79750 1.02652 $35k-$50 77 20.42440 2,397 15.58720 0.76317 $50k-$75k 71 18.83289 3,502 22.77279 1.20920 $75k-$100k 44 11.67109 2,118 13.77292 1.18009 $100k-$150k 39 10.34483 1,584 10.30043 0.99571 $150k+ 10 2.65252 602 3.91468 1.47584 Note: The weighting ratios are calculated by taking the ratio of the proportion of the population of Defiance County in each subcategory by the proportion of the sample in the Defiance County survey for that same category. * Defiance County population figures taken from the 2016 Census. ** Due to the small sample of respondents in the 20-24 age group, this was combined with the 25-34 age group for weightings.

APPENDIX III: METHODS FOR WEIGHTING | 145

Appendix IV: School Participation

The following schools were randomly chosen and agreed to participate in the 2018 Defiance County Health Assessment:

Ayersville Local Ayersville Junior High Ayersville High School

Central Local Fairview Middle School Fairview High School

Defiance City Defiance Middle School Defiance High School

Hicksville Hicksville Middle School Hicksville High School

Northeastern Local Tinora Junior High Tinora High School

APPENDIX IV: SCHOOL PARTICIPATION | 146

Appendix V: Defiance County Sample Demographic Profile*

Defiance County Census 2018 Survey Variable 2012-2016 (5-year Ohio Census 2016 Sample estimate) Age

20-29 3.0% 11.7% 13.4% 30-39 5.1% 12.0% 12.3% 40-49 10.2% 11.9% 12.2% 50-59 14.7% 14.8% 14.2% 60 plus 64.9% 23.3% 22.9%

Race/Ethnicity

White 91.2% 91.7% 84.1% Black or African American 0.9% 1.9% 14.2% American Indian and Alaska Native 0.2% 0.4% 0.8% Asian 0.2% 0.4% 2.6% Other 1.9% 4.4% 1.2% Hispanic Origin (may be of any 4.9% 9.5% 3.6% race)

Marital Status†

Married Couple 59.1% 54.4% 47.4% Never been married/member of an unmarried couple 11.9% 26.2% 32.5% Divorced/Separated 11.9% 13.2% 13.8% Widowed 14.4% 10.5% 6.3%

Education†

Less than High School Diploma 7.2% 7.7% 10.0% High School Diploma 37.7% 44.6% 33.3% Some college/ College graduate 53.7% 40.0% 56.7%

Income (Families)

$14,999 and less 6.6% 6.8% 7.7% $15,000 to $24,999 14.2% 6.7% 6.8% $25,000 to $49,999 28.8% 24.2% 21.2% $50,000 to $74,999 16.5% 26.4% 20.4% $75,000 or more 21.6% 35.9% 44.1% * The percents reported are the actual percent within each category who responded to the survey. The data contained within the report however are based on weighted data (weighted by age, race, sex, and income). Percents may not add to 100% due to missing data (non- responses).

† The Ohio and Defiance County Census percentages are slightly different than the percent who responded to the survey. Marital status is calculated for those individuals 15 years and older. Education is calculated for those 25 years and older.

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Youth Variable 2018 Youth Survey Sample Age

11 years old or younger 3.2% 12 years’ old 12.5% 13 years’ old 18.1% 14 years’ old 18.5% 15 years’ old 12.3% 16 years’ old 14.2% 17 years’ old 12.7% 18 years old or older 7.5%

Gender

Male 53.4% Female 46.6%

Race/Ethnicity

White 89.8% American Indian and Alaska Native 8.0% Black or African American 3.7% Hispanic or Latino 14.1% Asian 0.2% Native Hawaiian or Other Pacific Islander 0.2% Other 6.3%

Grade Level

Middle School (6-8) 49.7% High School (9-12) 49.3%

Individual Grade Level

6th grade 12.5% 7th grade 15.9% 8th grade 21.3% 9th grade 12.7% 10th grade 12.5% 11th grade 12.7% 12th grade 11.4%

*Percents may not add to 100% due to missing data (non-responses) or percent’s may exceed 100% due to respondents answering more than option.

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Appendix VI: Demographics and Household Information

Defiance County Population by Age Groups and Gender U.S. Census 2010

Age Total Males Females

Defiance County 39,037 19,225 19,812 0-4 years 2,489 1,298 1,191 1-4 years 2,016 1,044 972 < 1 year 473 254 219 1-2 years 981 514 476 3-4 years 1,035 530 505 5-9 years 2,721 1,343 1,378 5-6 years 1,068 530 538 7-9 years 1,653 813 840 10-14 years 2,762 1,420 1,342 10-12 years 1,663 856 807 13-14 years 1,099 564 535 12-18 years 4,370 2,290 2,080 15-19 years 2,738 1,435 1,303 15-17 years 1,631 846 785 18-19 years 1,107 589 518 20-24 years 2,291 1,150 1,141 25-29 years 2,229 1,113 1,116 30-34 years 2,244 1,108 1,136 35-39 years 2,385 1,180 1,205 40-44 years 2,358 1,196 1,162 45-49 years 2,774 1,347 1,427 50-54 years 3,044 1,503 1,541 55-59 years 2,833 1,432 1,401 60-64 years 2,312 1,185 1,127 65-69 years 1,756 840 916 70-74 years 1,373 649 724 75-79 years 1,062 469 593 80-84 years 872 338 534 85-89 years 505 165 340 90-94 years 222 46 176 95-99 years 63 8 55 100-104 years 4 0 4 105-109 years 0 0 0 110 years & over 0 0 0 Total 85 years and over 794 219 575 Total 65 years and over 5,857 2,515 3,342 Total 19 years and over 28,852 14,022 14,830

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DEFIANCE COUNTY PROFILE

General Demographic Characteristics (Source: U.S. Census Bureau, Census 2015)

2012-2016 ACS 5-year estimate

Total Population 2016 Total Population 38,488 2012 Total Population 38,975

Largest City-Defiance City 2016 Total Population 16,676 100% 2010 Total Population 16,494 100%

Population By Race/Ethnicity Total Population 38,488 100% White Alone 35,301 91.7% Hispanic or Latino (of any race) 3,661 9.5% African American 734 1.9% Asian 162 0.4% Two or more races 807 2.1% Other 1,676 4.4% American Indian and Alaska Native 139 0.4%

Population By Age Under 5 years 2,223 5.8% 5 to 9 years 2,560 6.7% 10 to 14 years 2,661 6.9% 15 to 19 years 2,749 7.1 % 20 to 24 years 2,414 6.3% 25 to 44 years 9,043 23.5% 45 to 64 years 10,386 27% 65 years and more 6,452 16.7% Median age (years) 39.9

Household By Type Total Households 15,378 100% Family Households (families) 10,675 69.4% With own children <18 years 4,100 38.4% Married-Couple Family Households 8,075 52.5% With own children <18 years 2,700 33.4% Female Householder, No Husband Present 1,791 11.6% With own children <18 years 963 53.8% Non-family Households 4,703 30.6% Householder living alone 3,752 24.4% Householder 65 years and > 1,507 9.8%

Households With Individuals < 18 years 4,721 30.7% Households With Individuals 65 years and > 5,997 39.0%

Average Household Size 2.46 people Average Family Size 2.97 people

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General Demographic Characteristics, Continued (Source: U.S. Census Bureau, Census 2016)

2012-2016 ACS 5-year estimate

Median Value of Owner-Occupied Units $109,400 Median Monthly Owner Costs (With Mortgage) $6,942 Median Monthly Owner Costs (Not Mortgaged) $4,564 Median Gross Rent for Renter-Occupied Units $669 Median Rooms Per Housing Unit 6.1

Total Housing Units 16,712 No Telephone Service 327 Lacking Complete Kitchen Facilities 130 Lacking Complete Plumbing Facilities 34

Selected Social Characteristics (Source: U.S. Census Bureau, Census 2016)

2012-2016 ACS 5-year estimates

School Enrollment Population 3 Years and Over Enrolled In School 9,765 100% Nursery & Preschool 633 6.5% Kindergarten 405 4.1% Elementary School (Grades 1-8) 4,383 44.9% High School (Grades 9-12) 2,115 21.7% College, undergraduate 1,901 19.2% Graduate, professional school 328 3.4%

Educational Attainment Population 25 Years and Over 25,881 100% < 9th Grade Education 636 2.5% 9th to 12th Grade, No Diploma 1,993 7.7% High School Graduate (Includes Equivalency) 11,538 44.6% Some College, No Degree 4,982 19.2% Associate Degree 2,655 10.3% Bachelor’s Degree 2,717 10.5% Graduate or Professional Degree 1,360 5.3%

Percent High School Graduate or Higher *(X) 89.8% Percent Bachelor’s Degree or Higher *(X) 15.8% *(X) – Not available

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Selected Social Characteristics, Continued (Source: U.S. Census Bureau, Census 2016) 2012-2016 ACS 5-year estimate

Marital Status Population 15 Years and Over 31,044 100% Never Married 8,134 26.2% Now Married, Excluding Separated 16,888 54.4% Separated 621 2.0% Widowed 1,925 6.2% Female 3,260 10.5% Divorced 3,477 11.2% Female 3,539 11.4%

Veteran Status Civilian Veterans 18 years and over 2,722 9.3%

Disability Status of the Civilian Non-Institutionalized Population Total Civilian Noninstitutionalized Population 38,187 100% With a Disability 5,039 13.2% Under 18 years 9,067 100% With a Disability 20 0.9% 18 to 64 years 22,933 100% With a Disability 2,335 22.2% 65 Years and Over 6,187 100% With a Disability 2,224 75% Selected Economic Characteristics (Source: U.S. Census Bureau, Census 2016) 2012-2016 ACS 5-year estimates

Employment Status Population 16 Years and Over 30,555 100% In Labor Force 19,513 63.9% Not In Labor Force 11,042 36.1% Females 16 Years and Over 15,458 100% In Labor Force 9,102 58.9%

Population Living With Own Children <6 Years 2,465 100% All Parents In Family In Labor Force 1,623 65.8%

Class of Worker Employed Civilian Population 16 Years and Over 18,162 100% Private Wage and Salary Workers 15,295 84.2% Government Workers 1,854 10.2% Self-Employed Workers in Own Not Incorporated Business 978 5.4% Unpaid Family Workers 35 0.2%

Median Earnings Male, Full-time, Year-Round Workers $43,274 Female, Full-time, Year-Round Workers $32,141

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Selected Economic Characteristics, Continued (Source: U.S. Census Bureau, Census 2015)

2012-2016 ACS 5-year estimate Occupations Employed Civilian Population 16 Years and Over 18,162 100% Production, Transportation, and Material Moving 4,662 25.6% Management, Business, Science, and Art Occupations 4,674 25.7% Sales and Office Occupations 4,142 22.8% Service Occupations 2,973 16.3% Natural Resources, Construction, and Maintenance 1,171 9.4%

Leading Industries Employed Civilian Population 16 Years and Over 18,162 100% Manufacturing 5,127 28.2% Educational, health and social services 3,760 20.7% Trade (retail and wholesale) 2,575 14.2% Arts, entertainment, recreation, accommodation, and food 1,441 7.9% Construction 761 4.2% Agriculture, forestry, fishing and hunting, and mining 387 2.1% Other services (except public administration) 775 4.3% Professional, scientific, management, administrative, and waste 1,171 6.4% management services Transportation and warehousing, and utilities 741 4.1% Public administration 582 3.2% Finance, insurance, real estate and rental and leasing 681 3.7% Information 387 2.1%

Bureau of Economic Analysis (BEA) Per Capita Personal Income (PCPI) Figures

Income Rank of Ohio Counti BEA Per Capita Personal Income 2016 $37,687 51st of 88 counties BEA Per Capita Personal Income 2015 $36,784 57th of 88 counties

th BEA Per Capita Personal Income 2014 $36,181 40 of 88 counties BEA Per Capita Personal Income 2013 $35,210 41st of 88 counties

(BEA PCPI figures are greater than Census figures for comparable years due to deductions for retirement, Medicaid, Medicare payments, and the value of food stamps, among other things)

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Selected Economic Characteristics, Continued (Source: U.S. Census Bureau, Census 2016)

2012-2016 ACS 5-year estimate

Income In 2016 Households 15,378 100% < $10,000 818 5.3% $10,000 to $14,999 767 5.0% $15,000 to $24,999 1,622 10.5% $25,000 to $34,999 1,968 12.8% $35,000 to $49,999 2,397 15.6% $50,000 to $74,999 3,502 22.8% $75,000 to $99,999 2,118 13.8% $100,000 to $149,999 1,584 10.3% $150,000 to $199,999 329 2.1% $200,000 or more 273 1.8% Median Household Income $50,822

Income In 2015 Families 10,561 100% < $10,000 383 3.6% $10,000 to $14,999 297 2.8% $15,000 to $24,999 742 7.0% $25,000 to $34,999 1,068 10.1% $35,000 to $49,999 1,600 15.2% $50,000 to $74,999 2,728 25.8% $75,000 to $99,999 1,779 16.8% $100,000 to $149,999 1,538 14.6% $150,000 to $199,999 223 2.1% $200,000 or more 203 1.9% Median Household Income (families) $50,663

Per Capita Income In 2012-2016 $24,703

Poverty Status In 2016 % Below Poverty Level Families 10.0% Individuals 13.6% *(X) – Not available

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Poverty Rates, 5-year averages, 2012 to 2016

Category Defiance Ohio

Population in poverty 13.4% 15.8%

< 125% FPL (%) 18.2% 20.3%

< 150% FPL (%) 23.3% 24.8%

< 200% FPL (%) 32.9% 33.9% Population in poverty (2000) 6.2% 10.6%

(Source: The Ohio Poverty Report, Ohio Development Services Agency, February 2017, http://www.development.ohio.gov/files/research/P7005.pdf)

Employment Statistics* *Rate equals unemployment divided by labor force. Category Defiance Ohio

Labor Force 18,200 5,788,900

Employed 17,500 5,554,600

Unemployed 700 234,300

Unemployment Rate* in April 2018 4.1 4.0

Unemployment Rate* in March 2018 4.2 4.3

Unemployment Rate* in April 2017 4.8 4.6 (Source: Ohio Department of Job and Family Services, April 2018, http://ohiolmi.com/laus/OhioCivilianLaborForceEstimates.pdf)

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Estimated Poverty Status in 2016 90% Confidence 90% Confidence Age Groups Number Percent Interval Interval Defiance County All ages in poverty 3,876 3,198 to 4,554 10.4% 8.6 to 12.2 Ages 0-17 in poverty 1,293 1,015 to 1,571 15.1 11.9 to 18.3 Ages 5-17 in families in 857 655 to 1,059 13.3 10.2 to 16.4 poverty Median household income $48,345 to $52,210 $56,075 Ohio All ages in poverty 1,614,177 to 1,639,636 14.5 14.3 to 14.7 1,665,095 Ages 0-17 in poverty 506,894 to 521,730 20.4 19.8 to 21.0 536,566 Ages 5-17 in families in 335,691 to 348,713 18.7 18.0 to 19.4 poverty 361,735 Median household income $52,083 to $52,357 $52,631 United States All ages in poverty 44,022,086 to 44,268,996 14.0 13.9 to 14.1 44,515,906 Ages 0-17 in poverty 13,976,345 to 14,115,713 19.5 19.3 to 19.7 14,255,081 Ages 5-17 in families in 9,548,767 to 9,648,486 18.3 18.1 to 18.5 poverty 9,748,205 Median household income $57,502 to $57,617 $57,732 (Source: U.S. Census Bureau, Small Area Income and Poverty Estimates, http://www.census.gov/did/www/saipe/data/interactive/#)

Federal Poverty Thresholds in 2017 by Size of Family and Number of Related Children Under 18 Years of Age No One Two Three Four Five Size of Family Unit Children Child Children Children Children Children 1 Person <65 years $12,752 1 Person 65 and > $11,756 2 people $16,414 $16,895 Householder < 65 years 2 People $14,816 $16,831 Householder 65 and > 3 People $19,173 $19,730 $19,749 4 People $25,283 $25,696 $24,858 $24,944 5 People $30,490 $30,933 $29,986 $29,253 $28,805 6 People $35,069 $35,208 $34,482 $33,787 $32,753 $32,140 7 People $40,351 $40,603 $39,734 $39,129 $38,001 $36,685 8 People $45,129 $45,528 $44,708 $43,990 $42,971 $41,678 9 People or > $54,287 $54,550 $53,825 $53,216 $52,216 $50,840 (Source: U. S. Census Bureau, Poverty Thresholds 2017, https://www.census.gov/data/tables/time-series/demo/income-poverty/historical- poverty-thresholds.html)

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Appendix VII: 2018 County Health Rankings

Defiance Ohio U.S. County Health Outcomes Premature death. Years of potential life lost before age 75 per 100,000 population (age-adjusted) (2012- 7,100 7,700 6,700 2014) Overall heath. Percentage of adults reporting fair or 16% 17% 16% poor health (age-adjusted) (2015) Physical health. Average number of physically unhealthy days reported in past 30 days (age- 3.8 4.0 3.7 adjusted) (2015) Mental health. Average number of mentally unhealthy days reported in past 30 days (age- 3.9 4.3 3.8 adjusted) (2015) Maternal and infant health. Percentage of live births 6% 9% 8% with low birthweight (< 2500 grams) (2008-2014) Health Behaviors Tobacco. Percentage of adults who are current 21% 23% 17% smokers (2015) Obesity. Percentage of adults that report a BMI of 30 33% 32% 28% or more (2015) Food environment. Index of factors that contribute to a healthy food environment, 0 (worst) to 10 (best) 8.3 6.6 7.7 (2014) Physical activity. Percentage of adults aged 20 and 26% 26% 23% over reporting no leisure-time physical activity (2013) Active living environment. Percentage of population with adequate access to locations for physical activity 63% 85% 83% (2010 & 2014) Drug and alcohol abuse. Percentage of adults 18% 19% 18% reporting binge or heavy drinking (2015) Drug and alcohol abuse and injury. Percentage of 45% 34% 29% driving deaths with alcohol involvement (2011-2015) Infectious disease. Number of newly diagnosed 338 489 479 chlamydia cases per 100,000 population (2014) Sexual and reproductive health. Teen birth rate per 29 28 27 1,000 female population, ages 15-19 (2008-2014)

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Defiance Ohio U.S County Clinical Care Coverage and affordability. Percentage of population under age 65 without health insurance 8% 8% 11% (2014) Access to health care/medical care. Ratio of 1740:1 1,310:1 1,320:1 population to primary care physicians (2014) Access to dental care. Ratio of population to 2,940:1 1,660:1 1,480:1 dentists (2015) Access to behavioral health care. Ratio of 540:1 560:1 470:1 population to mental health providers (2016) Hospital utilization. Number of hospital stays for ambulatory-care sensitive conditions per 1,000 78 57 49 Medicare enrollees (2014) Diabetes. Percentage of diabetic Medicare enrollees 88% 85% 85% ages 65-75 that receive HbA1c monitoring (2014) Cancer. Percentage of female Medicare enrollees ages 67-69 that receive mammography screening 68% 61% 63% (2014) Social and Economic Environment Education. Percentage of ninth-grade cohort that 95% 81% 83% graduates in four years (2014-2015)

Education. Percentage of adults ages 25-44 years 56% 65% 65% with some post-secondary education (2011-2015) Employment, poverty, and income. Percentage of population ages 16 and older unemployed but 5% 5% 5% seeking work (2015) Employment, poverty, and income. Percentage of 15% 20% 20% children under age 18 in poverty (2015) Employment, poverty, and income. Ratio of household income at the 80th percentile to income 3.7 4.8 5.0 at the 20th percentile (2011-2015) Family and social support. Percentage of children that live in a household headed by single parent 31% 36% 34% (2011-2015) Family and social support. Number of membership 18.0 11.3 9.3 associations per 10,000 population (2015) Violence. Number of reported violent crime 97 290 380 offenses per 100,000 population (2012-2014) Injury. Number of deaths due to injury per 100,000 65 75 65 population (2011-2015)

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Defiance Ohio U.S. County Physical Environment Air, water, and toxic substances. Average daily density of fine particulate matter in micrograms per 11.2 11.3 8.7 cubic meter (PM2.5) (2012) Air, water, and toxic substances. Indicator of the presence of health-related drinking water violations. 1 - indicates the presence of a Yes N/A N/A violation, 0 - indicates no violation (FY 2013-2014) Housing. Percentage of households with at least 1 of 4 housing problems: overcrowding, high housing 12% 15% 19% costs, or lack of kitchen or plumbing facilities (2009- 2013) Transportation. Percentage of the workforce that 88% 83% 76% drives alone to work (2011-2015) Transportation. Among workers who commute in their car alone, the percentage that commute more 26% 30% 35% than 30 minutes (2011-2015) (Source: 2018 County Health Rankings for Defiance County, Ohio and U.S. data) N/A – Not Available

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