Oklahoma Task Force to Eliminate Health Disparities

FINAL REPORT · JULY 2006 Oklahoma Task Force to Eliminate Health Disparities

Final Report ● July 2006

Table of Contents

Oklahoma Task Force to Eliminate Health Disparities Members ...... iii

Executive Summary...... 1

Introduction...... 3

Health Disparities in Oklahoma...... 5

Findings and Recommendations from the Subcommittees...... 6

Suggested Readings ...... 26

References...... 28

Appendices...... 29

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Oklahoma Task Force to Eliminate Health Disparities Members

Claudia Barajas, Latino Agency Community Development Center

Sen. Bernest Cain, Oklahoma State Senate

Dr. Nancy Chu, University of Oklahoma, College of Nursing

Dorothy Gourley, Consultant Pharmacist

Annette Johnson, Sickle Cell Department, Children’s Hospital

Dr. Sohail Khan, Cherokee Nation Health Services

Carter Anthony McBride, Retired, Pharmaceutical Industry

Tim O’Connor, Director, Catholic Charities

Sen. Constance N. Johnson, Oklahoma State Senate

Maria Palacios, Community Service Council of Greater Tulsa

Mike Parkhurst, Guymon Public School

Chester Phyffer, Pastor, Christ United Methodist Church

Brad Stanton, Community Health Center Consultant

Rep. Opio Toure, Oklahoma House of Representatives

Jean Wood, Oklahoma Department of Mental Health and Substance Abuse Services

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Executive Summary

In 2003 Senate Bill 680 created the Oklahoma Task Force to Eliminate Health Disparities. Initially, twelve members representing the Oklahoma Legislature and diverse members of Oklahoma’s population made up the Task Force. The Governor, President Pro Tempore of the Senate, Speaker of the House of Representatives, and the State Commissioner of Health each made three appointments. In 2004 an amendment to Senate Bill 680 added three new members to represent mental health concerns. The Task Force was charged to assist the State Department of Health investigate issues related to health disparities and health access (e.g., availability of health care providers, cultural competency, and behaviors that lead to poor health) among multicultural, underserved and regional populations; develop short-term and long-term strategies to eliminate health disparities, focusing on cardiovascular disease, infant mortality, diabetes, cancer and other leading causes of death; publish a report on the findings and recommendations for implementing targeted programs to move Oklahoma closer to a state of health through the reduction and eventual elimination of health disparities. Health status in Oklahoma continues to decline. Since the late 1980s, Oklahoma is the only state in the nation in which age-adjusted death rates have been increasing. Over the past several years, the State of the State’s Health Report has underscored the state’s unacceptable health status. Oklahoma continues to have some of the highest rates of heart disease, diabetes, cancer, and other chronic health conditions. The reasons for Oklahoma’s poor health status are complex and multi-faceted. Many Oklahomans lack health insurance and cannot afford the cost of adequate health care. A significant decrease in chronic health conditions would result from improving poor health behaviors. Simply put, we need to adopt healthy lifestyle choices: eat better, exercise more and avoid tobacco use. However, the disparity evident in population groups for certain diseases, health outcomes and access to health care is one of the most critical factors that accounts for Oklahoma’s poor health status. Three subcommittees were formed to tackle the complex multi-cultural, and economic issues associated with health disparities: 1) Cultural Competency; 2) Enhanced

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Data Capacity; and 3) Health Access. Significant recommendations of the subcommittees are summarized below:

Cultural Competency Subcommittee • Deliver cultural competency training to both healthcare providers and the institutions through which they provide services, including addressing the prevalence of emotional and physical violence in communities. Language barriers should be eliminated between healthcare providers and healthcare recipients, and culturally competent language assistance should be provided for limited English proficiency (LEP) populations.

Data Subcommittee • Build a standardized statewide, integrated data collection and analysis system that meets all current Health Insurance Portability and Accountability Act (HIPAA) standards and state laws. Developing such a data system will lay the foundation for clearly identifying health disparities in Oklahoma and serve as the main tool to evaluate the effectiveness of interventions designed to eliminate health disparities.

Health Care Access Subcommittee • Develop collaborative partnerships between communities and federal, state and local agencies to work on key cultural and communication barriers that impact health access and health education. One such partnership effort is Oklahoma Turning Point, which has been endorsed by the Oklahoma State Board of Health as a vehicle for systems change – improving overall health status in Oklahoma. Other key issues include supporting the development of training programs that expand the number of minorities among mental health and substance abuse professionals, administrators and policymakers; and provide intensive public awareness to policy makers and health improvement partners on the need to insure access to health care in order to reduce the burden of poor health status experience by Oklahoma’s ethnic and minorities populations.

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Introduction

As the State of the State’s Health Report has underscored over the past several years, Oklahoma’s health status remains unacceptable. The state continues to have some of the highest rates of heart disease, diabetes, cancer, and other health conditions. More important, since the late1980s, Oklahoma has been the only state in nation in which age adjusted death rates have actually been increasing. The reasons for Oklahoma’s poor health status are multi-faceted. Economics no doubt play a role, as many Oklahomans simply cannot afford adequate health care or preventive services. Improving our poor health habits could contribute to a decrease in the development of chronic health conditions. Simply put, we need to adopt healthy lifestyle behaviors: eat better, exercise more, and avoid tobacco use. One of the most critical factors that accounts for Oklahoma’s poor health status, though, is the disparity seen in population groups for certain diseases, health outcomes and access to health care. This report translates the work of the Oklahoma Task Force to Eliminate Health Disparities, and makes recommendations on action steps to move Oklahoma closer to a state of health through the reduction and eventual elimination of health disparities. The Task Force, created in 2003 by Senate Bill 680, was charged to assist the State Department of Health to:

• Investigate issues related to disparities in health and health access among multicultural, underserved, and regional populations. These issues include, availability of health care providers, cultural competency, and behaviors that lead to poor health status. • Develop short-term and long-term strategies to eliminate health disparities, focusing on cardiovascular disease, infant mortality, diabetes, cancer and other leading causes of death. • Publish a report on the findings and make recommendations for implementing targeted programs for the elimination of health disparities.

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The Task Force originally consisted of twelve members representing the Oklahoma Legislature and diverse members of Oklahoma’s population. Three appointments were made each by the Governor, the President Pro Tempore of the Senate, the Speaker of the House of Representatives, and the State Commissioner of Health. In 2004 an amendment to SB 680 added three new members who represented mental health concerns. Members quickly realized that to make progress on the complex multi-cultural, and economic issues associated with health disparities, they would have to organize the work into subcommittees. These subcommittees included cultural competency, data, and health access, and are briefly described below.

Cultural Competency A critical issue identified that affects health disparities is cultural competency. Being culturally competent potentially improves care and may aid in reducing the burden of health disparities. Cultural competency training should take place in agencies and health care settings. In addition, cultural competency training should be a standard curriculum component for health career students. Eventually, the goal should be to celebrate our diversity, treating people equally, and ultimately eliminating disparities in health care.

Enhanced Data Capacity A prerequisite for effectively resolving health disparities is to identify what specific disparities exist through the careful analysis of data. Therefore, enhancing data capacity and identifying data resources that clearly define disparities among population groups are musts. Ideally, we should be able to link data from other agencies – creating a clearinghouse of reliable health-related data for the state of Oklahoma. This will help us to better understand what is happening today in order to improve the health status of tomorrow.

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Health Access As cited by the Oklahoma State Board of Health, one crucial action that can have a direct impact on reducing health disparities is increasing opportunities for health access among minority population groups.1 This can be done in a number of innovative ways including reducing disparities in funding for health among minority population groups, increasing the number of minority health care providers in all areas by working in creative ways with universities and colleges to recruit and retain more minority students in health care training programs, and by working with community partnerships for the development of community health centers and voluntary health clinics.

These three areas, cultural competency, data, and health access, form the foundation of the recommendations from the Oklahoma Task Force to Eliminate Health Disparities. The remainder of this report provides a brief overview of identified health disparities in Oklahoma, followed by the recommendations from each subcommittee.

Health Disparities in Oklahoma

A number of data reports were prepared by the Data Subcommittee of the Task Force, and are attached as appendices. However, some specific disparities were identified and are summarized below:

• Native Americans smoke at higher rates (34.9%) than the rest of the Oklahoma population, followed by African Americans (31.8%), Whites (23.4%), and Hispanics (17.3%). (2004 BRFSS) • African American women are almost twice as likely to die from breast cancer compared to White women. (2004 Oklahoma Vital Statistics) This may be due to delayed diagnosis in African American women, resulting in a more advance stage of the disease before treatment is provided. • African Americans are more likely to die from heart disease (345.3 deaths per 100,000 population) than Whites (293.1 deaths per 100,000 population). (2004 Oklahoma Vital Statistics)

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• High rates of obesity are seen among Hispanics, Native Americans, and African Americans. (2003 BRFSS) • Higher rates of diabetes exist among Native Americans (11.3%) and African Americans (9.5%) compared to Whites (6.6%). (2003 BRFSS)

As detailed in the attached data reports, multiple disparities exist in the health status, health access, and health care treatment of Oklahoma ethnic minority populations. However, disparities also exist for Oklahomans with less education and lower incomes, regardless of race and ethnicity. The work of the Oklahoma Task Force to Eliminate Health Disparities just begins to identify health disparities in Oklahoma, and perhaps leads to more questions than answers. Without question, though, the work of the Task Force draws attention to the desperate need for greater awareness and more sustained efforts to be directed toward eliminating health disparities in Oklahoma’s diverse populations. With that basic fact established, the Oklahoma Task Force to Eliminate Health Disparities offers the following recommendations from the three Subcommittees. If fully implemented, these recommendations would contribute to significant progress toward eliminating health disparities in Oklahoma and eventually lead to a much improved health status for Oklahomans overall.

Findings and Recommendations from the Subcommittees

Cultural Competency Subcommittee

In a generic sense, the term cultural competency has come to mean having the sufficiency to serve the characteristics of a civilization.2 And though specific characteristics of specific populations exist in many parts of Oklahoma, the concept, as it is applied to healthcare by this subcommittee, is not differentiated from one population (culture) to the next. In essence, this summary of the application brings attention to the challenges and opportunities that exist in both assessing and changing the healthcare provider industry’s ability to adequately serve the diversity of populations comprising Oklahoma.

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This summary reflects the findings of the Cultural Competency Subcommittee as it worked to meet its mission: to develop recommendations to the Oklahoma State Departments of Health (OSDH) and Mental Health (OSDMH) regarding disparities in healthcare from the perspective of culture. Working in harmony to identify and report their ideas, goals, and strategies relating to cultural aspects of healthcare, Subcommittee members derived this content over the course of several years and many meetings. The synergy and focus of its members came about due to commonly held, core interests and principles: (1) the acceptance of the common goal to address cultural competency in healthcare delivery as it crosses racial and ethnic barriers; (2) strong, wise leadership; (3) the willingness of leaders to follow; and (4) respect, and the value of applying it to others in order to become culturally competent. The overlay of culture to health and healthcare adds a dimension having both challenges and opportunities for stakeholders. The challenging side brings issues related to:

• Perceptions of fairness by populations that do not receive the kind of health service(s) that others receive; • Concerns for the systemic costs of change and new delivery methods outside of traditional budgeting and board-directed service venues; • Learning how to link with diverse populations that aren’t necessarily mainstream Oklahomans, or who may not have the means to obtain healthcare; • A general lack of awareness of the role that culture(s) play in the lives of many residents; and • Changes in both personal behaviors, and “how” and “why” healthcare services are institutionalized and ultimately delivered through public and private systems.

The opportunities bring to the table the possibility to:

• Positively impact the health in populations that are growing in number and diversity in our State, or who are not now adequately represented or served by healthcare systems;

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• Improve the awareness, confidence, and responsiveness to treatment and healthcare services outside of traditional institutional systems; • Comply with federal initiatives and other health-related mandates; and • Generally improve the health of everyone through collective efforts to serve those populations with limited or no healthcare.

Potential sources of disparities include: (1) systems-level inequities related to finances, structure, culture, and language; (2) patient-level preferences, including refusal of treatment, poor adherence to instructions, and biological differences; and (3) situational disparities within the clinical encounter, reflective of bias, prejudice, uncertainty, stereotyping, and distrust between provider and consumer. Demographic factors prefacing disparities include: race, gender, age; income; insurance status; rural or urban location; sexual orientation; housing status; and occupation or health behaviors.3 Examples of disparities include: African American men having a rate of prostate cancer double that of Caucasian men; Women of Vietnamese origin having cervical cancer at the rate of five times that of Caucasian women; Injury-related death rates being 40% higher in rural populations than in urban settings; Infant mortality rates of African American, American Indian and Alaska natives being double that of Caucasians. The role of cultural competency involves five essential elements:

1. Valuing diversity; 2. Having the capacity for cultural self-assessment; 3. Being conscious of the dynamics inherent when cultures interact; 4. Having institutionalized cultural knowledge; and 5. Having developed adaptations of service delivery reflecting an understanding of cultural diversity.

With those concepts in mind, the subcommittee developed eight outcomes of interest (goals) having related approach strategies:

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Goal 1: Cultural competency training should be delivered to both healthcare providers and the institutions through which they provide services, including addressing the prevalence of emotional and physical violence in communities.

Strategies: • Require OSDH employees and contractors to take a minimum of 3 hours of cultural competency training that would complete the following model as specified by OSDH policy, or as applicable: Awareness Self-assessment Dynamics of difference Institutionalization Change/adaptation • Require OSDH to collaborate with licensure boards to mandate integration of cultural competency training into continuing educational unit (CEU) annual requirements. • Require OSDH to collaborate with institutions of higher learning to increase the curriculum requirements for cultural competency training during internships, practicum, and clinical rotations. • Encourage OSDH Board of Health members to embrace and promote competence and diversity by: Recruiting minority members; Attending 3 hours of cultural competency training annually; Supporting and facilitating recommendations of the Health Disparities Task Force.

Goal 2: The trust and confidence that minority populations have in healthcare providers should be increased and improved.

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Strategies: • Strongly encourage members of the OSDH Board of Health to embrace, promote, and become proactive in: Cultural competence Cultural diversity Eliminating health disparities, by creating and implementing an action plan and/or rules to address these issues. • The members of the OSDH Board of Health should actively promote the involvement of professional associations in adopting such a plan or rules. • The OSDH Board should be encouraged to add a Board member that represents cultural diversity, and utilize the Health Disparities Task Force Cultural Competency Subcommittee as an advisory committee.

Goal 3: Language barriers should be eliminated between healthcare providers and healthcare recipients, and culturally competent language assistance should be provided for limited English proficiency (LEP) populations.

Strategies: • The OSDH shall provide its employees and contractors the tools, materials, and resources necessary for language assistance, including: Electronic interpreter services; A language line; Certified medical interpreters, including for the hearing impaired population; Use of a Review Committee for written (translated) items; Accessing the language and cultural expertise that exists within local community and volunteer organizations (Latino United League of American Citizens, Latino Community Development Agency, etc.); Convening educational training events (i.e., conversational Spanish, Vietnamese, Korean classes, or other specific language); Assistance with technical matters;

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Software for translating materials; Website for LEP applications and uses, including Alta Vista and free translation; Modifying PHOCIS to ask for special accommodations and other assistance as needed.

Goal 4: Culturally appropriate health/wellness education for LEP populations should be developed and implemented through public schools and community-based efforts.

Strategies: • The OSDH shall partner with: the State Departments of Education, Special Education, Mental Health/Substance Abuse, Human Services; and the Oklahoma School Board Association, Indian Health Services, Office of Juvenile Affairs, all Native American Indian Tribes, the Oklahoma Commission on Children and Youth, the Oklahoma Institute for Child Advocacy, the Oklahoma Turning Point Initiative, the Veterans Administration Medical Center, State Career Tech, NAACP, Parent Teachers Associations, and Parent Teacher Organizations, OU Health Sciences, OSU, all faith communities in Oklahoma, minority medical associations, Areawide Aging Agency services, Area Health Education Centers, Area Prevention Resource Centers, and others, to develop, train, implement, and evaluate culturally appropriate health and wellness education plans.

Goal 5: Bilingual and minority healthcare providers should be recruited and hired to reflect the populations being served.

Strategies: • Provide education and assistance to include scholarships, grants, loans, loan forgiveness, reimbursements, etc., which will include work payback to participating community programs;

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• Identify and network with recruiters who are culturally competent; • Establish target numbers of bilingual and minority providers and staff, reflective of populations being served.

Goal 6: Recommend changes in the Task Force’s goals to include other recommendations going to other groups and agencies.

Strategies: • Recommend that the Task Force amend its goals and objectives to include applications to all agencies and organizations that contribute to the improvement of health and wellness of Oklahomans.

Goal 7: Identify a baseline of health and healthcare disparities.

Strategies: • Begin efforts to identify and report health disparity baselines in all parts of the State in order to effectively measure progress from intervention strategies.

Goal 8: Mandate an annual “public health report card.”

Strategies: • Mandate an annual health report card, statewide, that responds to efforts and activities aimed at correcting or augmenting strategies, goals, and objectives within the subject area of health disparities, distributed to the Office of the Governor, all Cabinet Secretaries, the State Legislature, the media, the public, and all federal and state agencies, for the purpose of creating an open and accessible means of “seeing” and “reporting” findings and progress, and to recognize effective leadership and positive results.

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Data Subcommittee

“Health disparities will never disappear without compelling proof that they exist in the first place.”4

This opening quote summarizes very succinctly the mission of the Data Subcommittee of the Oklahoma Task Force to Eliminate Health Disparities. Data that clearly illustrate health disparities among population groups are critical not only to make the case for intervention, but also to measure the effectiveness of interventions aimed at eliminating disparities. Although data does not necessarily translate into action or political will to make change, it nonetheless lays the foundation for change to indeed happen and make an impact. With compelling data as the foundation, it is then up to all of us to demand action from our legislative leaders, our government agencies, and our health care providers. With these thoughts in mind, the Data Subcommittee identified three major themes through its research and analysis. First, disparities do exist in Oklahoma. Disparities exist in health access, health care coverage (health insurance), and appropriate treatment, often resulting in negative health outcomes. These identified disparities include but are not limited to, race and ethnicity, geographic location, age, gender, socio-economics (education, income level), education and language. Second, health disparities occur in the context of broader historic and contemporary social and economic inequality, and possible discrimination in many sectors of Oklahoma life due to lack of understanding of cultural differences. While strides have been made in trying to eliminate health disparities, there is often a break within the health continuum between patients, various levels of healthcare (state and local), and policy, which creates disparities within population groups across the state of Oklahoma. This disconnect, may be caused by bias, stereotyping, and prejudice within the continuum of health care and may contribute to disparities in Oklahoma. Health care providers, at one end of the continuum of health care, may contribute to disparities in

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Oklahoma. Patients, through lack of awareness, cultural beliefs and attitudes, at the other end of the continuum of health care, may contribute to disparities in Oklahoma. Third, there is currently insufficient data, data collection systems, and resources to identify all of the factors that may contribute both directly and indirectly to health disparities in Oklahoma. As a result, it is difficult to identify all definite direct and indirect factors (barriers) that contribute to the break within the health continuum. Programs that seek to eliminate health disparities may be limited in meeting the essential needs of targeted populations because of insufficient data systems available to measure current disparities and evaluate the effectiveness of interventions. The three major findings resulted in the Data Subcommittee developing three major sets of recommendations – general data recommendations, data collection and monitoring, and research needs:

General Data Recommendations • Raise the awareness of health professionals, state, county and community leaders of the important issue of health disparities and the adverse impact to the state of Oklahoma. • Support community-based activities to eliminate health disparities, and create greater accountability through such measures as diversifying governing boards and program staff. • Foster appreciation of the diversity of Oklahoma by healthcare providers through education and continuing education credits. • Enhance and assure that the statewide system of community referrals (211) includes free and reduced cost health services that can assist in reducing health disparities in Oklahoma. • Standardize the definition of health disparity at the state level.

Data Collection and Monitoring • Build a standardized statewide, integrated data collection and analysis system, that meets all current Health Insurance Portability and Accountability Act (HIPAA) standards and state laws.

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• Collect and report data on health care access and utilization by patients’ demographics (including but not limited to gender, race, ethnicity, socioeconomic status, geographic location, and primary language). • Integrate disparities measures in ongoing quality improvement and monitor changes in racial and ethnic disparities in care over time. . • Create systems to collect data on patient race and ethnicity that are consistent state and nationwide (including five minimum race codes and ethnicity as per OMB Directive 15). • Provide funding and adequately trained staff to work with all appropriate state agencies and data collection sources and monitor progress toward the elimination of health disparities. • Provide training, technical assistance and support to community programs to properly collect and analyze data on health disparities. • Improve/encourage data linkage between state agencies and health providers to further evaluate the impact of health care services on outcomes and their link to disparities. • Provide data on health disparities to organizations, agencies, and academic institutions that educate health care providers, administrators, policy makers, consumers, and the media.

Research Needs • Support the program evaluation and research that identify best practices to reduce health disparities in Oklahoma. • Research on health and disease must be interdisciplinary, encompass multiple levels of analysis, integrate across all levels of health care, and include the patient’s perspective. • Encourage disparities assessment related to socio-ecological factors (including but not limited to housing, environment, geography, and family). • Focus on the factors underlying good health, as well as disease. • Conduct research on ethical issues related to eliminating disparities. • Develop better methods to link data sets.

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• Provide opportunities for collaboration between and among state agencies, academic institutions, and private sectors to conduct research on eliminating health disparities in Oklahoma.

Although the Data Subcommittee feels that each of these recommendations is important, the first key recommendation that should be accomplished is to build a standardized statewide, integrated data collection and analysis system, that meets all current HIPPA standards and state laws. Such a system was proposed legislatively during the 2006 Oklahoma Legislature (SB 1636); however, the bill was not heard on the House Floor. Consequently, the Data Subcommittee strongly urges the Oklahoma State Department of Health and the Oklahoma Department of Mental Health and Substance Abuse Services to collaborate and pilot an integrated health data system, which could eventually be expanded statewide. Developing such a data system will lay the foundation for clearly identifying health disparities in Oklahoma and serve as the main tool to evaluate the effectiveness of interventions designed to eliminate health disparities.

Health Care Access Subcommittee

The Health Care Access Subcommittee developed a list of recommendations to address the issue of health care access in the state. These recommendations were drafted: (1) in terms of identifying health care access needs for the state’s underserved populations, including those representing Oklahoma’s racial and ethnic minority communities; and (2) in consideration of recent and ongoing state efforts to address health care access through funding initiatives (e.g., Tobacco Tax and provider reimbursement), insurance coverage, community health centers, prescription drug access, breast and cervical cancer treatment, research, trauma care and state Medicaid reform. While the recommendations are designed for implementation by the Oklahoma State Department of Health (OSDH) and the Oklahoma State Department of Mental Health and Substance Abuse Services (ODMHSAS), the Subcommittee affirms that in reality, health care access is the responsibility for all committed to ensuring health care access for the state’s populations. Therefore, establishing collaborative partnerships to

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achieve health care access on behalf of those with the greatest health needs is a continuing priority for these two state agencies. Further, in looking at the larger picture, these recommendations are considered to be part of an evolving, ongoing process. Health care access, within the context of health disparities, is a challenging undertaking that requires long-term commitment and that should continue to be a high priority for the state beyond the existence of the Task Force. There are no easy answers. In consideration of these issues, the Subcommittee developed the following recommendations:

• Develop training programs to increase the number of minorities among mental health and substance abuse professionals, administrators and policymakers. • Develop a centralized health disparities data link through the OSDH Web site to provide an easily accessible source of current, reliable information for health professionals, policymakers, researchers, students and the general public. • Work with the University of Oklahoma College of Public Health (OU COPH) and the University of Oklahoma College of Medicine to increase the number of minorities in the health professions, (e.g., physicians, nurses, health educators, epidemiologists, environmentalists, etc.). • Develop an ongoing preventive health education and awareness campaign involving the OSDH, ODMHSAS, Office of the Governor, legislative officials, and other partners to draw attention to health disparity issues through the assurance of health care access. This would include activities such as, radio and television spots, newspapers, press releases, town-hall meetings, and other community forums. Faith-based organizations and schools may also participate in this awareness campaign. • Develop collaborative partnerships between communities and federal, state and local agencies to work on key cultural and communication barriers that impact health access and health education.

Although not part of the recommendations, a variety of topics affecting health care access were also discussed and considered, including, but not limited to:

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• Encouraging diversity training for state medical and health professionals; • Increasing school-based clinics with sufficient staffing of nurses; • Convening a state health disparities conference; • Developing a health needs assessment for racial and ethnic populations at the county and local level; • Decreasing utilization rates of emergency room care; • Ensuring access through primary care by increasing the number of community health centers and providing adequate reimbursement for providers, hospitals and clinics; and • Enhancing the capacity of the Oklahoma Turning Point initiative to address health disparities at the local “grass roots” level.

Although definitions vary, health care access is generally defined as the “timely” use of health services to achieve the “best possible outcomes” 5 including preventive care and ongoing care. Factors that impact health care access include insurance coverage, education, income, health care costs, language barriers, cultural beliefs and attitudes, provider location, service availability, transportation, etc. Health access is identified as both a leading health indicator and as a health objective of Healthy People 2010 ,6the Nation’s health objectives for the 21st century. Locally, in its 2002 State of the State’s Health Interim Report, Health Disparities: the haves & have-nots, the Oklahoma State Board of Health acknowledged the importance of health care access as a “positive” impact on health disparities.7 The OSDH has also added health care access among its agency priorities.8 In a review of reports and through testimony, the Subcommittee found a variety of challenges at both the state and national level. Nationally, the proposed cuts in safety net programs such as Medicaid and Medicare;9 the continuing trend of increasing numbers of uninsured persons, including immigrants;10 the concerns regarding the escalating costs and affordability of health care;11 and the reporting of disparities in treatment and access for minorities, including mental health,12 all point to the difficulty in ensuring health care access for the nation’s population, including the nation’s vulnerable and underserved persons. Adding to these difficulties are perceptions concerning the seriousness of access

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and health care – these too have proven to be significant issues that require appropriate attention. For example, a 2005 survey conducted on behalf of the Robert Wood Johnson Foundation found that 68 percent of Americans were “unaware” that racial and ethnic minorities receive poorer care than Whites, with the greatest lack of awareness among Whites.13 However, the same survey reported that most of the respondents believed that all Americans deserve equal care.14 Also, the Centers for Disease Control and Prevention point out that “unequal” access to care and unequal treatment of persons who receive care are “key determinants” of racial/ethnic disparities in health care and health status.15 In its review of health access in Oklahoma, the Subcommittee also found that the state is confronted by a variety of lingering issues that have significant impact the state’s ability to develop health access reforms. These following factors contribute to the challenge of ensuring health care access : (1) developing minority health professionals, including African American and Hispanic medical school graduates and physicians;16 (2) reducing the high percentage of uninsured persons in the state, most notably Hispanics at 40%;17 (3) ensuring collaboration and communication between state policymakers and local community stakeholders with diverse cultural backgrounds; (4) developing cultural competence and cultural sensitivity among health professionals; (5) integrating mental health and primary care services; (6) developing accessible and accurate data to determine the extent of health access and health disparities issues both nationally and locally; (7) improving the socio-economic factors (i.e., education, income, economic development, etc.) contributing to the inability of persons and businesses to afford rising health care costs; (8) reducing the utilization of emergency rooms and trauma centers as a primary source of care; and (9) ensuring the availability of adequate services and resources (i.e., physicians, transportation, community health centers, etc.) in communities with the greatest health needs. For example, some of these issues are visibly highlighted in a 2006 report of the health care system in the Tulsa area, which generally finds it to be inadequate. The report further finds that access to health care would be greatly improved with the expansion of community health centers; school-based health clinics; the establishment of patient-referral linkages and the tracking of patient records.18 Access to health care has driven much of the recent health initiatives in the state, including state-subsidized insurance coverage, prescription drug access, provider

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reimbursement, trauma care, breast and cervical cancer treatment and proposed reforms to the state Medicaid system. The tax on tobacco products recently passed by Oklahoma voters could be a major funding source to support many of these initiatives. While much has been accomplished during the tenure of the Task Force, more work still needs to be done. Both the OSDH and ODMHSAS are encouraged to: (1) address health access and health disparities issues internally though strategic planning, reporting and collaboration; and (2) consistently collaborate with outside agencies and community partners such as the Oklahoma Health Care Authority, the Department of Human Services, the Oklahoma Primary Care Association, Central Oklahoma Project Access, Oklahoma Foundation for Medical Quality University of Oklahoma College of Public Health, various colleges, universities, medical schools, and hospitals . Traditional and “non-traditional” alliances are encouraged to advance new ideas and remove barriers to health access for those with the greatest health needs.

Recommendations

1. Support the development of training programs that expand the number of minorities among mental health and substance abuse professionals, administrators and policymakers.

Rationale: As the general population increasingly becomes more culturally diverse, the incidence of mental health disorders among individuals from diverse racial and ethnic groups will also increase. Clinicians trained in traditional, Western biomedical psychiatry and other mental health professions will face new challenges in evaluating these individuals. Therefore, understanding of psychological functioning and mental disorders must be based on knowledge of these diverse groups.

Strategy: Support the development of curricula of training and professional programs that explicitly encompass racial and cultural aspects and differences, which may affect access to, and effectiveness of, such programs. Conduct

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evidence-based research to examine whether such training curricula and professional programs are effective. These curricula must be flexible enough to be updated regularly so that they can be inclusive of the expanding knowledge base.

2. Develop a centralized health disparities data link through OSDH Web site.

Rationale: Intended to provide researchers, health professionals, students, and the general public access to a central source or clearinghouse of current, reliable information related to health disparities. Currently, persons seeking health disparities information must navigate their way through a complicated research process. This website would streamline that process.

Strategy: With the OSDH Communications Service taking a lead role, develop a link of relevant health disparities information, including the Turning Point initiative, University of Oklahoma Health Science Center (OUHSC) research studies, Healthy People 2010, health disparities initiatives, funding opportunities, and calendar of events. A specific website that most closely resembles this is the Colorado Minority Health Forum, a Turning Point initiative.

3. Collaborate with the University of Oklahoma COPH and the University of Oklahoma College of Medicine to increase the number of minorities in the health professions.

Rationale: Experts believe that having a greater percentage of racial and ethnic minorities in the health care field will help decrease culture and language barriers with the heath care system and help ensure more providers are available in ethnic and minority communities. By and large, physicians have not been trained to provide culturally competent care. This is a strategic starting point to address health disparities. “Cultural competence” education teaches medical/ health care providers how to more effectively address patients’ cultural beliefs and behaviors. Also, the medical system lacks prepared information that is culturally appropriate

Oklahoma Task Force to Eliminate Health Disparities ● Final Report ● July 2006 21

(written, audio, video) to convey culturally sensitive messages in many Asian languages.

Strategy: Collaborate with the University of Oklahoma College of Public Health and University of Oklahoma College of Medicine to develop a pilot program that encourages minority institutions to train, recruit and retain talented minority undergraduate students in the biomedical and behavioral sciences. Offer scholarships and enhanced financing for medical school. Incorporate mandatory cultural competency training in the medical school curriculum (starting at undergraduate level prerequisites and continuous throughout medical school, internship, medical board exam, etc.) This would help ensure that cultural competency becomes an institutionalized “practice” and not merely a “refresher” course. Partner with Oklahoma colleges and universities and the Department of Education to develop outreach programs to encourage participation of minority high school and college students in research (especially from a multidisciplinary perspective). Develop new ways to inform minority students about training opportunities in health disparities research, including informational reports, Websites (i.e., MEDLINEplus), tracking systems to assess the effects of programs, and conferences with faculty from Hispanic-Serving institutions, Historically Black Colleges and Universities (HBCUs), Tribal colleges and universities, and other academic centers, including participation in annual meetings of minority professional and medical associations. A possible long-term benefit would be to encourage the OSDH and ODMHSAS to hire these trained professionals as both interns and full-time employees consistent with agency hiring polices.

4. Assist in the development of an ongoing preventive health education and awareness campaign involving the OSDH, ODMHSAS, the Governor, legislative officials and other partners to address health disparities issues through the assurance of health care access. This may include activities such as, radio and

Oklahoma Task Force to Eliminate Health Disparities ● Final Report ● July 2006 22

television spots, newspapers, and community forums. Churches and schools may also participate in this awareness campaign.

Rationale: This can bring awareness on an ongoing basis to the public of the serious healthcare access issues that are present in the state. A new perspective will be to focus on health disparities to complement current health care initiatives promoted by state policymakers and health leaders. This will also provide an opportunity for state leaders to address continuing reports of the poor health status of Oklahoma’s population, driven largely by the poor health condition of racial and ethnic populations. Examples of these types of leadership efforts include the president of Oklahoma University spearheading the development of a diabetes prevention center;19 and (2) the governor of Pennsylvania getting involved in a public campaign to shed light on the severity of health disparities in that state.20

The development of a consistent preventive health campaign on a statewide basis can help in prioritizing health concerns among children and families; fostering improved relationships between health care providers and patients with different cultural backgrounds; enhancing health literacy and awareness for racial and ethnic populations; and generally, creating a healthier workforce that will lead to improved opportunities for economic development for the state.

Strategy: Provide support to a consistent ongoing public awareness campaign developed to focus on preventive health education and health awareness information. The campaign would utilize all media driven opportunities (i.e., television, radio, newspaper (local/statewide), churches, and health agency functions that focus on positive outcomes management). The program would target health promotion activities using state leaders, key members of influence throughout the state (i.e., the Governor and/or high ranking legislators/ private citizens, etc.) This initiative would be directed to inform, communicate, and initiate public awareness and activities that will promote healthy outcomes, prevention strategies and ongoing health management updates. The intended

Oklahoma Task Force to Eliminate Health Disparities ● Final Report ● July 2006 23

outcome would be to increase total health awareness and promote healthy behaviors, attitudes, activities, and quality of life of Oklahoma populations both socially and economically. The OSDH and ODMHSAS communication departments would serve as the point of contact in this collaborative effort.

5. Encourage the OSDH and ODMHSAS to develop collaborative partnerships with local communities and federal state and local agencies to work on key cultural barriers that may impact health access and health education.

Rationale: The issue of accessibility of health care for the underserved envelops a mirage of possible socio-cultural as well as economic etiologies. Definitions and emerging solutions should not only be on a holistic scale across the state but also community- specific. Many community (local), state and federal agencies have developed coalitions, taskforce groups, agencies, and federally funded programs to address specific health issues. Most are working independently and have limited knowledge of what possible partners can be connected under the same mission and goals. By having local, state, and federal partners working more collaboratively together monetary and goal-oriented achievements can be developed, implemented, and evaluated for effectiveness to reach the target audience. This would also decrease the amount of duplication of services. Many counties also may need assistance in building needed councils to address health issues to be presented to influence future creations of policy or amendments to current policy.

Strategy: Develop a database whereby local, state and federal programs/groups that are working on similar issues can be grouped. This database can be used for identifying various potential collaborative partners for coalition building and community-based program development. This can be linked on various programs within the OSDH and ODMHSAS to demonstrate that collaboration is taking place on various levels to ensure optimal health care. This could include a structured reporting system among the relevant health and mental health program

Oklahoma Task Force to Eliminate Health Disparities ● Final Report ● July 2006 24

areas within the OSDH and ODMHSAS. In addition, a possible mechanism would be to have meetings (i.e., quarterly, semi-annually) between the entities with impact on health access: i.e., OSDH, ODMHSAS, Oklahoma Health Care Authority, Oklahoma Primary Care Association, the Department of Human Services, Turning Point, hospitals, clinics, medical schools, faith-based organizations, etc.) to discuss common health care access issues, concerns and program areas.

Finally, the Oklahoma State Board of Health has endorsed Turning Point as the vehicle the OSDH will use to improve health in Oklahoma. The Oklahoma Turning Point initiative is transforming public health in the state by establishing successful health education/ health promotion programs through community partnerships. Funded in part by a grant from the Robert Wood Johnson and W.K. Kellogg foundations, Turning Point was launched in January 1998 with three pilot community partnerships in Cherokee, Texas, and Tulsa counties. Each of these “model” partnerships achieved significant success in assessing local needs, establishing local priorities and implementing strategies tailored to the unique needs of the community at large. The key objective for Oklahoma Turning Point is to develop and expand similar community health improvement partnerships into each of the state’s 77 counties. Currently, there are 50 community partnerships located throughout the four quadrants of the state – Regional Turning Point Field Consultants provide technical assistance to assist the partnerships in identifying local health priorities, implementing strategic health improvement plans, and evaluating program impact. In addition, the Oklahoma State University Cooperative Extension Service (located in each county of the state) can help facilitate the community development aspect by creating tools that assist local groups with community leadership training. Using a community participatory base for developing solutions, state and federal agencies can connect with these community partners to address key health issues. This will create and foster buy- in from the community that will generate successful outcomes.

Oklahoma Task Force to Eliminate Health Disparities ● Final Report ● July 2006 25

Suggested Readings

Agency for Healthcare Research and Quality (AHRQ). (2003). National Healthcare Disparities Report. Rockville, MD: U.S. Dept. of Health and Human Services.

Betancourt, J.R., Green, A.R., Carrillo, J. E. (2002). Cultural competence in health care: Emerging frameworks and practical approaches. Commonwealth Fund pub. No. 576. New York: Commonwealth Fund. www.cmwf.org

BPHC. (2001). Cultural competence works. Bethesda, MD: HRSA. www.bphc.hrsa.gov

Carter-Pokras, O., & Baquet, C. (2002). What is a “Health Disparity”? Public Health Reports, 117, 426-433.

Cross, T, Bazron, B, Dennis, K., & Isaacs, M. (1989). Toward a culturally competent system of care, Vol. 1. Washington DC: Georgetown University.

Drexler, Madeline (2005). Health Disparities & the Body Politic. Harvard School of Public Health Symposium 2005. Boston, MA: Harvard School of Public Health.

HRSA (2001). Cultural competence works. Rockville, MD: HRSA Center for Managed Care. www.hrsa.gov/financemc/

HRSA Care Action. (2002, August). Mitigating health disparities through cultural competence. HRSACare Action. http://hab.hrsa.gov

HRSA. (2000) Eliminating health disparities in the United States. Rockville, MD: HRSA

Kitchen, A. (1999) Treating immigrant populations-Cultural competence in health care. Bioethics Forum, 15(2), 11-17.

Oklahoma Task Force to Eliminate Health Disparities ● Final Report ● July 2006 26

Majumdar, B., Browne, G., Roberts, J., Carpio, B. (2004). Effects of cultural sensitivity training on health care provider attitudes and patient outcomes. Journal of Nursing Scholarship 26(2), 161-166.

McDonough, J.E., Gibbs, B.K., Scott-Harris, J. L., Kronebusch, K, Navarro, A.M., & Taylor, K. (2004). A state policy agenda to eliminate racial and ethnic health disparities. Commonwealth Fund pub. No. 746. New York, Commonwealth Fund. www.cmwf.org

Saldana, D. (2001) Cultural competency: A practical guide for mental health service providers. Austin TX: Hogg Foundation. www.hogg.utexas.edu

Trevalon, M. (2003). Components of culture in health for medical students’ education. Academic Medicine, 78(6), 570-576.

Youdelman, M., & Perkins, J. (2005). Providing language services in small health care provider settings: Examples from the field. Commonwealth Fund pub. No. 810. New York: Commonwealth Fund. www.cmwf.org

Oklahoma Task Force to Eliminate Health Disparities ● Final Report ● July 2006 27

References

1 The Haves and the Have-Nots: Health Disparities. 2002 State of the State’s Health Interim Report. Oklahoma State Board of Health. July 2002.

2 Webster’s International 2nd

3 HRSA, 2001

4 Health Disparities & the Body Politic. Harvard School of Public Health Symposium Series 2005.

5 National Health Disparities Report, 2004.

6 U.S. Department of Health and Human Services. “Healthy People 2010”. www.healthypeople.gov.

7 OSDH Board of Health, 2002 State of the State’s Health Interim Report, “The Haves & Have-Nots”.

8 OSDH, Office of the Commissioner.

9 Kaiser Daily Health Report, March 31, 2005. www.kaisernetwork.org.

10 Kaiser, Ibid., June 14, 2005.

11 Kaiser, Ibid., September 6, 2005.

12 U.S. Centers for Disease Control and Prevention, Office of Minority Health. Issue Brief: “Eliminating Racial and Ethnic Disparities. Date unknown. www.cdc.gov/omh

13 Robert Woods Foundation, “American Views of Disparities in Health Care”, December 9, 2005.

14 Ibid.

15 U.S. Centers for Disease Control and Prevention, MMRW Weekly, August 27, 2004.

16 Kaiser Foundation Health Report, Oklahoma, 2005.

17 Ibid.

18 Janet Pearson, “ OSU Medical School Plight Part of a Bigger Health Crisis,” Editorial. Tulsa World, May 7, 2006.

19 Daily Oklahoman, December 9, 2005.

20 Kaiser Daily Health Report, April 21, 2006.

Oklahoma Task Force to Eliminate Health Disparities ● Final Report ● July 2006 28

Appendices

Oklahoma Task Force to Eliminate Health Disparities ● Final Report ● July 2006 29 Oklahoma Task Force to Eliminate Health Disparities

D A T A R E P O R T · S E P T E M B E R 2 0 0 4

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 I Contents

1 Summary and Key Findings

Health Risks, Medical Care Coverage, and Other Indicators 3 Percent of Female Respondents 40 years of Age and Older Who Had Not Had a Mammography in 2 Years or More by Sub-State Planning Districts: Oklahoma 2001-2003 4 Percent of Adult Reporting Having Had their Cholesterol Checked in the Past 5 Years by Sub-State Planning Districts: Oklahoma 2003 5 Percent of Adult Respondents Reporting Having Been Told by a Doctor, Nurse, or Other Health Professional that You have High Blood Pressure by Sub-State Planning Districts: Oklahoma 2003 6 Percent of Adult Respondents Having Flu Shot in Past 12 Months Among People with Diabetes by Sub-State Planning Districts: Oklahoma 2001-2003 7 Percent of Adult Respondents Having Pneumonia Vaccination among People with Diabetes by Sub-State Planning Districts: Oklahoma 2001-2003 8 Percent of Adult Respondents Not Tested for HIV by Sub-State Planning Districts: Oklahoma 2003 9 Rate of Paid Claim Data for Immunization Among Medicaid Patients by Sub-State Planning Districts: Oklahoma 2003 10 Percent of Adult Respondents Reporting Not Participating in a Leisure Time Physical Activity During the Past Month by Sub-State Planning Districts: Oklahoma 2003 11 Percent of Adult Respondents Reporting an Obese Body Mass Index (BMI) (>=30.0) by Sub-State Planning Districts: Oklahoma 2003 12 Percent of Adult Respondents Reporting an Overweight Body Mass Index (BMI) (>=25.0) by Sub-State Planning Districts: Oklahoma 2003 13 Percent of Adult Respondents With Any Kind of Health Plan by Sub-State Planning Districts: Oklahoma 2001-2003 14 Percent of Adult Respondents Reporting that There Was a Time During the Last 12 Months When You Needed to See a Doctor but Could Not because of the Cost by Sub-State Planning Districts: Oklahoma 2003 15 Percent of Adult Respondents Reporting Currently Smoking Cigarettes by Sub-State Planning Districts: Oklahoma 2003 16 Percent of Adult Respondents Reporting Currently Using Smokeless Tobacco by Sub-State Planning Districts: Oklahoma 2002

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 I Incidence of Diseases 17 Percent of Cancer Diagnosed at Regional or Distant Stage by Sub-State Planning Districts: Oklahoma 1997-2001 18 Age-Adjusted Incidence Rate Colon and Rectum Cancer by Sub-State Planning Districts: Oklahoma 1997-2001 19 Age-Adjusted Incidence Rate Lung and Bronchus Cancer by Sub-State Planning Districts: Oklahoma 1997-2001 20 Age-Adjusted Incidence Rate Prostate Cancer by Sub-State Planning Districts: Oklahoma 1997-2001 21 Rate of Paid Claim Data with a Diagnosis of Cardiovascular Disease among Medicaid Patients by Sub-State Planning District: Oklahoma 2003 22 Percent of Adult Respondents Reporting Having Been Told by a Doctor That You Have Diabetes by Sub-State Planning Districts: Oklahoma 2003 23 Rate of Paid Claim Data with a Diagnosis of HIV Among Medicaid Patients by Sub-State Planning Districts: Oklahoma 2003

Death Rates 24 Percent of Alcohol Related Deaths Among all Deaths by Sub-State Planning Districts: Oklahoma 1999 Age-Adjusted Mortality Rate Cancer of the Lung and Bronchus by Sub-State Planning Districts: Oklahoma 1997-2001 25 Age-Adjusted Mortality Rate Cancer of the Lung and Bronchus by Sub-State Planning Districts: Oklahoma 1997-2001 26 Age-Adjusted Mortality Rate Cancers of the Colon, Rectum, and Anus by Sub-State Planning Districts: Oklahoma 2002 27 Age-Adjusted Mortality Rate for Diabetes by Sub-State Planning Districts: Oklahoma 2002 28 Age-Adjusted Mortality Rate Ischemic Heart Disease by Sub-State Planning Districts: Oklahoma 2002 29 Age-Adjusted Mortality Rate Cardiovascular Disease by Sub-State Planning Districts: Oklahoma 2002 30 Age-Adjusted Mortality Rate Influenza and Pneumonia by Sub-State Planning Districts: Oklahoma 2002 31 Infant Mortality Rate by Sub-State Planning Districts: Oklahoma 2002 32 Mortality Rate Homicide by Sub-State Planning Districts: Oklahoma 1996-2002 33 Mortality Rate Suicides by Sub-State Planning Districts: Oklahoma 2002 34 Age-Adjusted Mortality Rate Motor Vehicle Crash Deaths by Sub-State Planning Districts: Oklahoma 2002

II Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 Summary and Key Findings

This report represents the work completed by the Data Committee of the Oklahoma Task Force to Eliminate Health Disparities for year one of the Task Force mandate. Participating agencies and groups in the Data Committee included:

• Absentee Shawnee Tribe • Cherokee Nation • Integris Mental Health • Northeast Oklahoma Community Health Center • Oklahoma City Area Indian Health Service • Oklahoma City Area Inter-Tribal Health Board • Oklahoma Department of Commerce • Oklahoma Department of Human Services • Oklahoma Department of Mental Health and Substance Abuse Services • Oklahoma Foundation for Medical Quality • Oklahoma Health Care Authority • Oklahoma Primary Care Association • Oklahoma State Department of Health • Oklahoma State House of Representatives • Oklahoma State Senate • Paradox A. I. Research • University of Oklahoma

To begin the process of identifying health disparities through available data, committee members agreed on several principles dealing with what data to review, how the data would be combined from the different participating agencies and groups, and what key benchmarks to look at (i.e., years 1997 through most current available data and standard age categories). The end result was a comprehensive database of indicators representing the combined data of the participating agencies and groups. Just having produced this very preliminary database was a significant outcome, since data from these different agenices and groups had never been combined in this way before.

In addition to the basic principles on what data to collect and how it would be com- bined into a single database, the group decided that the primary way to report analyses would be through regional planning districts, graphically displayed on maps of Oklahoma. Each data map also includes a brief narrative of bullet points, providing additional information on the particular health indicator. Copies of the data charts for each of these maps and bullet points may be downloaded at http://www.health.state. ok.us/commish/disparities.html. Technical notes about these charts also may be found at this location.

Although this is the initial, year one report of the Data Committee, some key findings have already been identified, which will lead the committee to further investigations.

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 1 These findings include:

• High rates of elevated blood pressure among African Americans. • High rates of diabetes among Native Americans. • High rates of obesity among African Americans, Hispanics, and Native Americans. • Disparities in affordable medical care for African Americans and Native Americans. • Possible treatment disparities among African Americans, resulting in higher death rates for cardiovascular disease and certain cancers.

As the Data Committee of the Oklahoma Task Force to Eliminate Health Disparities continues its work, these key findings and other areas of concern identified through this report will be further analyzed. Rather than focusing on regional differences as this report did, the year 2 report will identify disparities within ethnicity, gender, and socio-economic groups.

2 Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 Percent of Female Respondents 40 years of Age and Older Who Had Not Had a Mammography in 2 Years or More by Sub-State Planning Districts: Oklahoma 2001-2003

• More women ages 40 and over receiving mammographies over time from 1997- 2003. • Fewer mammography screenings among women with less education. • Fewer mammography screenings among women with less income. • More mammography screenings among women with insurance coverage. • Hispanic women tend to receive mammography screenings less than other groups.

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 3 Percent of Adult Reporting Having Had their Cholesterol Checked in the Past 5 Years by Sub-State Planning Districts: Oklahoma 2003

• Those with increased education and income have better rates of cholesterol screening. • Those with insurance coverage are more likely to be checked for cholesterol. • Cholesterol screening rates among the white population are decreasing slightly over time. • Minority cholesterol screening rates are increasing over time. • Lowest cholesterol screening rates are in the northwest part of the state.

4 Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 Percent of Adult Respondents Reporting Having Been Told by a Doctor, Nurse, or Other Health Professional that You have High Blood Pressure by Sub-State Planning Districts: Oklahoma 2003

• Lower rates of high blood pressure as education and income increases. • Rates of high blood presssure increasing overall (possibly due to increases in obesity). • Rates of high blood pressure are higher among females than males. • Higher rates of high blood pressure are found in the east-central part of the state. • Highest rates of high blood pressure among African Americans.

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 5 Percent of Adult Respondents Having Flu Shot in Past 12 Months Among People with Diabetes by Sub-State Planning Districts: Oklahoma 2001-2003

• Rates for flu shots among those with diabetes increasing over time. • Rates for flu shots among those with diabetes are significantly lower for those without health insurance coverage. • Rates for flu shots among those with diabetes tend to increase as age increases.

6 Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 Percent of Adult Respondents Having Pneumonia Vaccination among People with Diabetes by Sub-State Planning Districts: Oklahoma 2001-2003

• Rates for pneumonia shots among those with diabetes increasing over time. • Rates for pneumonia shots among those with diabetes are significantly lower for those without health insurance coverage. • Rates for pneumonia shots among those wtih diabetes tend to increase as age increases.

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 7 Percent of Adult Respondents Not Tested for HIV by Sub-State Planning Districts: Oklahoma 2003

• African Americans are being tested more for HIV than other groups. • Fewer people getting tested for HIV in southeast and northwest Oklahoma.

8 Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 Rate of Paid Claim Data for Immunization Among Medicaid Patients by Sub-State Planning Districts: Oklahoma 2003

• Significant African American disparity for Medicaid immunization coverage. • Significant Hispanic disparity for Medicaid immunization coverage. • Central Oklahoma rates are worse than any other region in the state for Medicaid immunization coverage.

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 9 Percent of Adult Respondents Reporting Not Participating in a Leisure Time Physical Activity During the Past Month by Sub-State Planning Districts: Oklahoma 2003

• Lack of physical activity increases with age. • Physical activity increases with increased income. • Physical activity increases with increased education. • Disparity among the Hispanic population (less physical activity than any other group). • Females participate in physical activity less than males.

10 Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 Percent of Adult Respondents Reporting an Obese BMI (>=30.0) by Sub-State Planning Districts: Oklahoma 2003

• Huge increase in obesity among younger (20-29) age groups and in 60-69 age group. • Higher rates of obesity in Hispanics, African Americans, and Native Americans. • Obesity decreases with increase in income. • Those with college degree have lower rates of obesity.

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 11 Percent of Adult Respondents Reporting an Overweight BMI (>=25.0) by Sub-State Planning Districts: Oklahoma 2003

• The percent of those who are overweight steadily increased from 1997-2003. • African Americans and Native Americans have higher rates of being overweight than Hispanics. • Higher rates of being overweight in males than females. • Those reporting being overweight increasing more rapidly in the 20-29 age group. • Higher rates of being overweight correspond with increase in type 2 diabetes, especially in younger age groups. • High rate of increase of being overweight in 80+ age group. • Slightly lower rates of being overweight in urban areas.

12 Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 Percent of Adult Respondents With Any Kind of Health Plan by Sub-State Planning Districts: Oklahoma 2001-2003

• Clear disparity of lack of health plan coverage with younger ages. • Increased rate of health plan coverage with increased education and income. • Highest rates of health plan coverage among whites. • Lowest rates of health plan coverage in southeast Oklahoma.

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 13 Percent of Adult Respondents Reporting that There Was a Time During the Last 12 Months When You Needed to See a Doctor but Could Not because of the Cost by Sub-State Planning Districts: Oklahoma 2003

• Those unable to afford medical care increased greatly from 2000-2003. • Higher rates of being unable to afford medical care among those with lower incomes and education levels. • Higher rates of being unable to afford medical care among African Americans and Native Americans. • Females are much more likely than males to be unable to affored medical care. • Those in rural areas are more likely of being unable to afford medical care than those in urban areas.

14 Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 Percent of Adult Respondents Reporting Currently Smoking Cigarettes by Sub-State Planning Districts: Oklahoma 2002

• High rates of smoking among Native Americans. • Decreased smoking with increased age. • Decreased smoking with increased education. • Decreased smoking with increased income.

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 15 Percent of Adult Respondents Reporting Currently Using Smokeless Tobacco by Sub-State Planning Districts: Oklahoma 2003

• Overall increase of smokeless tobacco use in all age groups from 2001 to 2003. • Higher use of smokeless tobacco in 18-29 and 30-39 age groups. • Significant increase of smokeless tobacco use in Native Americans use over time and higher rates of use compared to other populations.

16 Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 Percent of Cancer Diagnosed at Regional or Distant Stage by Sub-State Planning Districts: Oklahoma 1997-2001

• Rates of cancer increase with age. • Rates of cancer have stayed steady over time. • Higher rates of cancer among African Americans. • Higher rates of cancer among males. • Higher rates of cancer among the very young.

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 17 Age-Adjusted Incidence Rate Colon and Rectum Cancer by Sub-State Planning Districts: Oklahoma 1997-2001

• Highest rates of colon cancer among African Americans. • Higher rates of colon cancer among males. • Rates of colon cancer increase with age.

18 Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 Age-Adjusted Incidence Rate Lung and Bronchus Cancer by Sub-State Planning Districts: Oklahoma 1997-2001

• Rates for lung cancer among males are almost twice as high as females. • Although there are improvements in smoking rates, lung cancer deaths have not caught up. • Lowest rates for lung cancer are in northwest Oklahoma and highest in southeast. • Lung cancer rates for Hispanics are beginning to decrease.

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 19 Age-Adjusted Incidence Rate Prostate Cancer by Sub-State Planning Districts: Oklahoma 1997-2001

• Significant disparity for prostate cancer among Native Americans. • Prostate cancer rates are worse for 60-69 and 70-79 age groups.

20 Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 Rate of Paid Claim Data with a Diagnosis of Cardiovascular Disease among Medicaid Patients by Sub-State Planning Districts: Oklahoma 2003

• African Americans are less likely to be treated for cardiovascular disease, which possibly links to the higher rate of death due to cardiovascular disease among this population. • High claim rate for cardiovascular disease in southeast Oklahoma.

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 21 Percent of Adult Respondents Reporting Having Been Told by a Doctor That You Have Diabetes by Sub-State Planning Districts: Oklahoma 2003

• Native Americans have the highest rates for diabetes. • African Americans have the second highest rates for diabetes. • Other (mixed ethnicities) also have high rates of diabetes. • Diabetes rates are worse for low income/low education. • Diabetes rates increase with age.

22 Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 Rate of Paid Claim Data with a Diagnosis of HIV Among Medicaid Patients by Sub-State Planning Districts: Oklahoma 2003

• HIV infection rates are highest among African Americans and increasing over time. • HIV infection rates are highest in the 30-49 age group. • HIV infection rates are higher in males.

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 23 Percent of Alcohol Related Deaths Among all Deaths by Sub-State Planning Districts: Oklahoma 1999

• Significantly high alcohol related death disparity among Native Americans. • Significantly high alcohol related death disparity among 10-19 and 20-29 age groups. • High rates of alcohol relatd deaths among Hispanics and African Americans.

24 Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 Age-Adjusted Mortality Rate Cancer of the Lung and Bronchus by Sub-State Planning Districts: Oklahoma 1997-2001

• Higher death rates of lung cancer in African Americans and Native Americans. • Higher death rates of lung cancer in males. • Lowest death rates of lung cancer in northwest Oklahoma, and highest rates in southeast Oklahoma. • African Americans have lower incidence rates of lung cancer but higher death rates, indicating possible heatlh access or treatment disparities.

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 25 Age-Adjusted Mortality Rate Cancers of the Colon, Rectum, and Anus by Sub-State Planning Districts: Oklahoma 2002

• Higher colon cancer deaths in African Americans and Native Americans. • Higher colon cancer deaths in males. • Increased colon cancer death rates as age increases. • Lower colon cancer death rates in urban areas suggesting health access and treatment issues.

26 Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 Age-Adjusted Mortality Rate for Diabetes by Sub-State Planning Districts: Oklahoma 2002

• Much higher rates of diabetes deaths among Native Americans and African Americans. • Increasing rates of diabetes deaths over time. • Highest rates of diabetes deaths in north central Oklahoma and lowest in north- west Oklahoma.

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 27 Age-Adjusted Mortality Rate Ischemic Heart Disease by Sub-State Planning Districts: Oklahoma 2002

• High ischemic heart disease deaths among African Americans and Native Americans. • High ischemic heart disease deaths among men. • Ischemic heart disease death rates are highest in southeast Oklahoma and lowest rates in northwest Oklahoma. • Lower ischemic heart death rates among Hispanics. • Ischemic heart disease deaths going down in all categories. • Ischemic heart disease deaths decreasing further in men than women. • Higher rates of ischemic heart disease deaths in rural areas, possibly due to lack of access to emergency care.

28 Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 Age-Adjusted Mortality Rate Cardiovascular Disease by Sub-State Planning Districts: Oklahoma 2002

• High cardiovasular disease deaths among African Americans and Native Americans. • High cardiovasular disease deaths among men. • Cardiovasular disease death rates are highest in southeast Oklahoma and lowest rates in northwest Oklahoma. • Lower cardiovasular disease death rates among Hispanics. • Cardiovasular disease deaths going down in all categories. • Cardiovasular disease deaths decreasing further in men than women.

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 29 Ag e-Adju sted Mo rtalit y Ra te Influ enza and Pn eumonia by Sub-State Planning Districts: Oklahoma 2002

• Higher death rates from influenza and pneumonia in rural vs. urban areas, prob- ably due to health access. • Higher death rates from influenza and pneumonia among males vs. females. • Highest rates of death from influenza and pneumonia in southwest Oklahoma.

30 Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 Infant Mortality Rate by Sub-State Planning Districts: Oklahoma 2002

• Disparity for infant mortality among African Americans. • Higher rates of infant mortality in southeast Oklahoma.

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 31 Mortality Rate Homicide by Sub-State Planning Districts: Oklahoma 1996-2002

• Clear disparity for deaths due to homicide among African Americans. • Clear disparity for deaths due to homicide among males. • Highest rates for deaths due to homicide in southeast Oklahoma, but decreasing. • Disparity for deaths due to homicide among the 20-29 and 30-39 age groups.

32 Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 Mortality Rate Suicides by Sub-State Planning Districts: Oklahoma 2002

• High suicide death rates among whites. • Highest suicide death rates among Native Americans. • Male disparity for deaths due to suicide. • Highest rates for deaths due to suicide in southeast Oklahoma.

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 33 Age-Adjusted Mortality Rate Motor Vehicle Crash Deaths by Sub-State Planning Districts: Oklahoma 2002

• Highest rates of deaths due to motor vehicle crashes among Native Americans. • Male disparity for deaths due to motor vehicle crashes. • Highest rates for deaths due to motor vehicle crashes in south central Oklahoma.

34 Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 Acknowledgment

This report was made possible by the collaborative efforts of the Data Committee of the Oklahoma Task Force to Eliminate Health Disparities. The Committee members’ willingness to share data and look at trends in a different way has been an important first step toward identifying health disparities in Oklahoma, which will lead to healthful solutions.

Committee Members:

Janis Campbell, Committee Chairperson, Oklahoma State Department of Health Pam Archer, Oklahoma State Department of Health Daryl Baker, University of Oklahoma Kelly Baker, Oklahoma State Department of Health Don Blose, Oklahoma State Department of Health B. J. Boyed, Cherokee Nation Senator Bernest Cain, Oklahoma State Senate Dan Cameron, Oklahoma City Area Indian Health Service Hannah Comstock, Oklahoma State Department of Health Joe L. Conner, Paradox A. I. Research Mary Daniel, University of Oklahoma Children’s Diabetes Center Marcia Goff, Staff, Oklahoma State House of Representatives Bunner Gray, Cherokee Nation Claudette Greenway, Oklahoma Foundation for Medical Quality Neil Hann, Oklahoma State Department of Health Leslie Harris, Absentee Shawnee Tribe J. Paul Keenon, Oklahoma Health Care Authority Sohail Khan, Cherokee Nation Marilynn Knott, Oklahoma Department of Human Services Sara Lassiter, Staff, Oklahoma State Senate Tracy Leeper, Oklahoma Department of Mental Heath and Substance Abuse Services Peng Li, Oklahoma State Department of Health Wendy Montemayor, Oklahoma City Area Inter-Tribal Health Board Becki Moore, Oklahoma Department of Mental Heath and Substance Abuse Services Joyce Morris, Oklahoma State Department of Health Paul Patrick, Oklahoma State Department of Health Anastasia Pittman, Staff, Oklahoma State Senate LaShonda Phillips, Integris Mental Health Angela Shoffner, Oklahoma Health Care Authority Brad Stanton, Northeast Oklahoma Community Health Center Carrie Tutor, Oklahoma State Department of Health Kelly Walkingstick, Oklahoma Foundation for Medical Quality Jeff Wallace, Oklahoma State Department of Commerce Brent Wilborn, Oklahoma Primary Care Association Ruby Withrow, Absentee Shawnee Tribe

Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004 35 Breast Cancer Disparities

P r o vi d e d b y : D a t a S u b c o m m i t t e e t o t h e O k l a h o m a T a s k F o r c e Breast Cancer Facts t o E l i m i n a t e H e a l t h D i s p a r i t i e s

Most common cancer White women were diagnosed in women in slightly (1.1 times) more the US and Oklahoma. likely to be diagnosed Volume 1, Issue 1 with breast cancer in November, 2004 2nd most common cause Oklahoma. of cancer death among African American women in US and women were 1.7 times For More Information Oklahoma. more likely to die from breast cancer compared Cheryl Jones, RN, Less than 1% of all to White women. Program Coordinator, breast cancers are Breast and Cervical Cancer Program, diagnosed in men. Over 40% of African- Chronic Disease Service, American and American 1 in 8 women will Indian women were Early Oklahoma State develop breast cancer diagnosed with breast Detection Department of Health during her lifetime. cancer at a regional or 405-271-4072 distant stage compared www.health.ok.gov Among Oklahoma to 29% of White and 33% BREAST CANCER women alive in 2000, of Hispanic women. SCREENING American Cancer Society www.cancer.org 250,680 will develop In 2002, Oklahoma • Perform monthly breast breast cancer sometime 1-800-ACS-2345 ranked as the 6th worst self examinations. in their lifetime. in the U.S. for the National Cancer Institute highest percentage of • Have a clinical breast www.cancer.gov Each year in OK: women who haven’t had exam every year after a mammogram in 5 or 1-800-4-CANCER • 2,500 women will be the age of 21. more years. diagnosed, and • Get your first screening Centers for Disease Control and Prevention • 475 will die of breast From 1997-2001, mammogram at 40 cancer. Oklahoma’s rate of years of age. www.cdc.gov breast cancer incidence Note: If you have risk Each year in the US: was better than the U.S. (70.3 vs. 72.5/100,000). factors for breast can­ Inside this issue: • 184,200 women will ` cer, you may need to be diagnosed, and In 1999-2001, Oklahoma have your mammogram Breast Cancer Facts 1 ranked 24th worst in at an earlier age. • 41,200 will die of Early Detection 1,3 breast cancer mortality breast cancer. Continued on page 3 in the U.S. Risk Factors 2 Risk Factors Incidence 2 Staging 3 Risk factors for breast Currently, the percent of future, however, the cancer include overweight women who are obese or percent of obesity or Mortality 4 or obesity, heavy alcohol overweight are similar overweight women in Good News! 4 use, limited physical between the US and activity and poor nutrition. Oklahoma. In the near Continued on page 2 More Information 1,4 Page 2 Breast Cancer Disparities

Task Force Committee Risk Factors– continued Claudia Barajas Sen. Bernest Cain Oklahoma will likely exceed that of U.S. vegetables. If this trend continues, Dr. Nancy Chu, OU women. Oklahoma women are more likely increasing rates of obesity and Annette Johnson, OUHSC to report they do not participate in overweight will not be far behind. Carter Anthony McBride `leisure-time physical activity and more Tim O’Connor likely to report they do not eat the Oklahoma women are less likely to Maria Palacios recommended levels of fruits and report heavy alcohol use. Mike Parkhurst Chester Phyffer Brad Stanton Prevalence of Cancer Risk Factors Dr. Gloria Teague BRFSS 2002 Rep. Opio Toure

At Risk for Heavy Alcohol 16.1 US Data Subcommittee Drinking 13.3 Oklahoma Janis Campbell, OSDH- Chair Overweight (BMI >=25) 37.0 35.8 Spender Anthony, OHCA Pam Archer, OSDH Obesity (BMI >=30) 22.2 22.9 Anne Bliss, OSDH No Leisure Time Physical 24.4 J. Boyd, Cherokee Nation Activity 30.6 Daryl Baker, OHCA <5 Fruits/Vegetables Per 76.7 Kelly Baker, OSDH Day 85.7 Don Blose, OSDH 0 10 20 30 40 50 60 70 80 90 100 Sen. Bernest Cain, OK State Senate Dan Cameron, IHS Percent Hannah Comstock, OSDH Joe L. Conner, Paradox A.I. Research Kym Cravatt, Cherokee Nation Mary Daniel, OUHSC Incidence Marcia Goff-House Staff Bunner Gray, Cherokee Nation Claudette Greenway, OFMQ Breast cancer incidence be diagnosed with breast Neil Hann, OSDH increases with age. As cancer. American Indian J.Paul Keenon, OHCA Sohail Khan, IHS women get older, their women are least likely to be Sara Lassiter, House Staff chance of being diagnosed diagnosed. Tracy Leeper, ODMHSAS with breast cancer increases. Peng Li, OSDH This may finding, however, Wendy Montemayor, IHS Becki Moore, ODMHSAS The risk of being diagnosed be less reflective of a Joyce Morris, OSDH– Tobacco Use with breast cancer also difference in the actual Barbara Neas, OUCOPH varies by race and ethnicity. disease process and more Paul Patrick—OSDH indicative of decreased or LaSahonda Phillips, Integris Health Anastasia Pittman, House Staff White women are more likely limited access to screening Angela Shoffner, OHCA than women of other races to opportunities. Brad Stanton, NEOCHC Carrie Tutor, OSDH Breast Cancer Incidence Breast Cancer Incidence Brent Wilborn, OKPCA by Age Oklahoma 1997-2001 by Race/Ethnicity Oklahoma 1997-2001 Kelly Walkingstick, OKQIO Jeff Wallace, ODC 350 Adeline Yerkes, OSDH Hispanic 66.5 300

250 American Indian 55.3 200 First Annual Data Report— Sept 2004 150 African-American 64.8 100 http://www.health.state.ok.us/ 50 commish/HDReport2004lowres.pdf White 71.6 0 <10 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80+ 0 10 20 30 40 50 60 70 80 90 100 Volume 1, Issue 1 Page 3

Early Detection: continued Women 40+ yrs without a Breast Cancer Screening Mammogram in 2 years BRFSS 2002 by Education Oklahoma

60 Clinical Breast Exam 88.6 50 in Last 2 Years 83.8

< HighSchool 40

Mammogram in Last 2 66.4 < HS/GED 30 Years Total 62.6 < SomeCollege

20 < CollegeGraduate 0 20 40 60 80 100 10 Percent 0 Oklahoma US 1997 1998 1999 2000 2001 2002 2003

Women 40+ yrs without a Women 40+ yrs without a Mammogram in 2 years Mammography in 2 years by Income Oklahoma by Insurance Status Oklahoma

60 80

70 50

60 < $15,000 40 Uninsured 50

< $15,000-$24,999 30 40 Total < $25,000-$34,999 Total < $35,000-$49,999 30 20

< $50,000+ 20 Insured 10 10

0 0 1997 1998 1999 2000 2001 2002 2003 1997 1998 1999 2000 2001 2002 2003

Staging

One in eight female breast cancers are Approximately 1 in 4 women (23.1%) Percent Survival by Stage diagnosed In situ and half (49.5%) are are diagnosed at a Regional stage and 1 diagnosed Localized. Women with in 20 are diagnosed at a Distant stage. either an In situ or Localized diagnosis Women who are diagnosed at an 5-yr relative have excellent chances of survival with advanced stage are less likely to Stage survival rate proper treatment. survive more than 5 years. 0-In Situ 100% Percentage Breast Cancers Diagnosed at Regional or Distant Stage: OCCR 1997-2001 I – Localized 98% IIA—Regional 88% IIB—Regional 76% Highest Rates IIIA—Regional 56% Moderately High Rate

State 35.7% Slightly Higher than the State IIIB—Regional 49% SWODA 35.9% Below the State Rates ACOG 35.9% IV—Distant 16% SODA 36.2% OEDA 37.3% KEDDO 39.0% GGEDA 41.6% For more information on the Task Force, contact: Mortality Connie Johnson, Sr. Legislative Analyst—Senate African American women are more likely to die from breast cancer 1-405-521-5776 than are White, American Indian or Hispanic women. [email protected] This is most likely related to delayed diagnosis which results in Marcia Goff Researcher– House both later stage disease and delays in treatment. 521-3201 Breast Cancer Mortality Rate Breast Cancer Mortality Rate [email protected] by Age Oklahoma 2002 by Race/Ethnicity Oklahoma 2002

120

For more information on the Data 100 Total 14.6 subcommittee, contact : 80 Hispanic 9.2 Janis Campbell, PhD 60 Chronic Disease Division, American Indian 14.6 40 Oklahoma State African-American 24.6 20 Department of Health. White 14.5 0 1000 NE 10th Street, <10 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80+ 0 10 20 30 Oklahoma City, OK 73117 1-405-271-4072 [email protected] Breast Cancer This publication, printed by Docutech, was issued by the Who gets it and who dies from it? Oklahoma State Department of Health as authorized by James M. Crutcher, MD,MPH. 1,000 copies were printed in March of Age -Adjusted Percent Regional Adjusted 2005 at a cost of $290.00. Copies have been deposited with the Publications Clearinghouse of the Oklahoma Department of Incidence Rate or Distant Stage Death Rate Libraries. Race 1997 -2001 1997 -2001 1999 -2001

Newsletter prepared by White 71.6 28.8% 13.9 Health Care Information African -American 64.8 40.4% 23.3 Division, Oklahoma State Department of Health American Indian 56.3 40.0% 14.2

Good News!

Breast and Cervical Cancer Available Services Treatment Medicaid Plan • Breast and cervical cancer and pre- Amendment cancer diagnosis and treatment Effective January 1, 2005, the State of Oklahoma began providing Medicaid • Medicaid coverage that includes benefits to uninsured women under 65, the full range of services (not only who are identified through the National cancer treatment) Breast and Cervical Cancer Early Detection Program (NBCCEDP) and Oklahoma Cares program • Medicaid eligibility continues until are in need of diagnosis and treatment the woman is no longer need for breast or cervical cancer (including breast or cervical cancer pre-cancerous conditions and early Client Eligibility treatment. stage cancer). • Income at or below 185% FPL Once a woman has an abnormal • SB 741– Amended May 2001 screening (clinical breast exam, Directs the Health Care Authority • No creditable insurance coverage mammogram, or pap smear) and has to develop a program for Medicaid been found to be in need of further diagnosis and treatment, you or your eligibility and services for • US Citizen or qualified alien individuals in need of breast or healthcare provider can call 1-866-550­ 5585 to see if you qualify and how to cervical cancer treatment. Oklahoma citizen • apply for Oklahoma Cares. • SB 978—April 2004 Appropriation

of $2 Million to Oklahoma Health • Abnormal finding on screening If you have been previously diagnosed Care Authority with breast or cervical cancer and are • Not otherwise eligible for Medicaid still undergoing treatment and meet all • HB 2552 – May 2004 “Belle of the other eligibility criteria, you may Maxine Hilliard Breast and be eligible for this program. Call the For more information, call this toll- Cervical Cancer Treatment Oklahoma State Department of Health free number: 866-550-5585 (V/TDD) Revolving Fund” to find out how. Oklahoma Disparities in Cardiovascular Disease P r o vi d e d b y : D a t a S u b c o m mi t t e e s o f t h e O k l a h o m a T a s k F o r c e t o E l i m i n a t e H e a l th D is p a r i t i e s a n d t he O k l a h o ma T u r n i n g What is Cardiovascular Disease? P o in t C o u n c i l

Cardiovascular Disease is a group of diseases that affects • Arrhythmia – irregularities of Volume 1, Issue 2 the heart and the circulatory the heart beat such as Atrial Fibrillation. system. This includes the February, 2005 muscles and nerves that Circulatory System Diseases support the heart, arteries, and veins. There are more than 60 • High Blood Pressure or For More Information: different types of cardiovascular Hypertension – restriction of disease. blood flow through the arteries of Misty D. Worley, MPH, CHES the body. Program Coordinator Carrie Tutor, M.S., Heart Diseases • High LDL (or Total) Epidemiologist • Congenital Heart Defects – Cholesterol – the build up of OK Heart Disease and structural problems with the plaque on the arteries leading to Stroke Health Program development of the heart. the heart and brain. Chronic Disease Service • Acute Myocardial Infarction – • Peripheral Vascular Disease – Oklahoma State heart attack. diseases of blood vessels outside Department of Health 405-271-4072 • Infections of the Heart, the heart and brain, most www.health.ok.gov endocarditis. commonly found in the lower extremities.. • Congestive Heart Failure – American Heart Association chambers of the heart fail to • Stroke – blockage of the blood function. vessels that supply oxygen and www.americanheart.org food to the brain. 1-800-AHA-USA-1 • Angina – chest pain caused by February th plaque in the vessels that feed the • Phlebitis – blockages in the 4 National Stroke Association veins. heart muscle. 2005 www.stroke.org 1-800-787-6537 1-800-STR-OKES

National Heart, Lung and Blood Oklahoma CVD Facts Institute www.nhlbi.nih.gov

•Heart disease and stroke •In 2003, heart disease to cardiovascular disease remain the 1st and 3rd caused 11,039 deaths in deaths. (1999-01). Inside this issue: leading causes of death OK, 5,403 were male and in Oklahoma. 5,636 were female, •Oklahoma’s (Age-Adjusted) What is CVD? 1 representing 31% of total CVD mortality rate is deaths. 411.6 per 100,000 CVD facts 1,4 •In 2003, heart disease and compared to the U.S. rate stroke accounted for over of 336.6 per 100,000. one-third of the total •Oklahoma ranks 50th in Risk Factors 1,2 deaths in Oklahoma. age-adjusted mortality due Continued on Page 4 Heart Disease Deaths 2 Risk Factors Red Dress Info 2 Prevalence of Risk 3

Non-Modifiable Life Habit (Modifiable) Other Diseases Cholesterol Screening 3 • Increasing Age • Cigarette Smoking • High Blood Cholesterol - Men ≥ 45 years - Low HDL cholesterol: <40 mg/dL ≥ - Women ≥ 55 years • Obesity (BMI 30) - Total blood chol: > 200 mg/dL Signs & Symptoms 3 • Overweight (BMI ≥ 25) • Gender: Male • Hypertension or HBP • Other contributors - Pre-hypertension: What Now? 4 Heredity >120-139/>80-89 mmHg • - Physical inactivity - Hypertension: ≥140/90 mmHg -Race/ethnicity - Poor nutrition - On anti-hypertensive medication Nat’l Performance 4 -Family history - Stress • Diabetes Measures (Medicare) Page 2 Oklahoma Disparities in Cardiovascular Disease

Task Force Committee Deaths Due to Heart Disease Claudia Barajas Sen. Bernest Cain An individual’s risk of dying from heart African Americans have the highest Dr. Nancy Chu, OU disease increases with age. Nearly 1 in rates of death due to heart disease in Annette Johnson, OUHSC 5 heart disease deaths occurs before Oklahoma (345.3/100,000), followed by Carter Anthony McBride age 65. Fully 1/3 of heart disease Whites (293.1) and American Indians Tim O’Connor deaths occur after age 85. (191.1) [2001]. Maria Palacios Mike Parkhurst Heart Disease Deaths by Selected Demographics: Deaths due to Heart Disease Chester Phyffer Oklahoma, 1999-2003 by Race and Ethnicity Oklahoma 1997-2002 Brad Stanton Age Deaths Population Death Rate White NH Black NH Am Indian (IHS Linked ) Hispanic Dr. Gloria Teague Under 1 41 244,840 16.7 400 Rep. Opio Toure 1-4 years 12 948,993 1.3 300 5-14 years 18 2,449,559 0.7 15-24 years 82 2,622,539 3.1 200 Data Subcommittee 25-34 years 186 2,274,199 8.2 100 35-44 years 1,043 2,559,365 40.8 0 Janis Campbell, OSDH- Chair 45-54 years 2,958 2,328,619 127.0 1997 1998 1999 2000 2001 2002 Rate per 100,000 Age-adjusted to 2000 US Population AI IHS Linked data unavailable for 2002) Spender Anthony, OHCA 55-64 years 5,600 1,642,658 340.9 Pam Archer, OSDH 65-74 years 9,483 1,209,378 784.1 There is concern that rates among Anne Bliss, OSDH 75-84 years 16,392 791,433 2,071.2 American Indians may be artificially 85+ years 19,254 287,975 6,686.0 J. Boyd, Cherokee Nation All rates are deaths per 100,000 population. low due to errors in racial Daryl Baker, OHCA Age-adjusted rates based on 2000 U.S. population standard. ICD10: Diseases of Heart: I11, I13, I20-I25, I00-I09, I26-I51 misclassification. A preliminary study Kelly Baker, OSDH based on death certificates linked with Don Blose, OSDH More than half of deaths due to heart the race data collected by the Indian Sen. Bernest Cain, OK State Senate disease occur among women, however, Health Service (IHS) suggests the Dan Cameron, IHS men die at an earlier age than women American Indian rates may actually be Hannah Comstock, OSDH do. When mortality rates are adjusted up to 50% higher. The linked rate for Joe L. Conner, Paradox A.I. Research for these age differences, the heart heart disease deaths to Oklahoma Kym Cravatt, Cherokee Nation disease mortality rate for men American Indians in 2001 was 298.0. Mary Daniel, OUHSC (371.5/100,000) is nearly 50% higher Rates of death due to heart disease Marcia Goff-House Staff than that of women (250.5/100,000) among Hispanics was lower at 194.0. Bunner Gray, Cherokee Nation [1999-2003]. Claudette Greenway, OFMQ Neil Hann, OSDH Go Red For Women J.Paul Keenon, OHCA Join women across America by supporting the Go Red Sohail Khan, IHS Sara Lassiter, House Staff For Women movement. Don't forget to call 1-888-MY­ Tracy Leeper, ODMHSAS HEART to receive your free red dress pin and wear it Peng Li, OSDH with pride. Get one. Give one. And Go Red For Women. Wendy Montemayor, IHS Becki Moore, ODMHSAS Joyce Morris, OSDH– Tobacco Use Barbara Neas, OUCOPH Paul Patrick—OSDH LaSahonda Phillips, Integris Health Risk Factors (continued) Anastasia Pittman, House Staff Angela Shoffner, OHCA Brad Stanton, NEOCHC Emerging Risk Factors ACDaDrriTeE TXuTtoTr,O OESXDPHL AIN PYRAMID • Lipoprotein(a) Death, Brent Wilborn, OKPCA Disability Kelly Walkingstick, OKQIO • Homocysteine RReeccuurrrreenntt Jeff Wallace, ODC • Prothrombotic factors CVD or Stroke Adeline Yerkes, OSDH • Proinflammatory factors FFirirsstt CCVVDD oorr SSttrrookkee • Impaired fasting glucose MMaajojorr RRisiskk FFaaccttoorrss First Annual Data Report— Sept 2004 http://www.health.state.ok.us/ • Subclinical atherosclerosis Advveerrsse Behavviiorrall Patttteerrnss Unffavorrablle Sociiall,, Economiic,, Culltturrall,, commish/HDReport2004lowres.pdf • Gum disease and Enviirronmenttall Condiittiions Volume 1, Issue 2 Page 3

Prevalence of Risk Factors

More of Oklahoma’s residents smoke compared to the nation, and it would Prevalence of CVD Risk Factors appear that Oklahomans are relatively BRFSS 2003 average as to overweight or obesity compared to the nation. This, however, 22.0 US may be of short-lived comfort. Cigarette Smoking 25.1 Oklahoma

37.0 Overweight (BMI 25.0-29.9)* Oklahoma residents are significantly 35.8 more likely not to participate in 22.2 Obesity (BMI >=30)* physical activity and six of seven 22.9 Oklahomans do not eat 5 or more No Leisure Time Physical 24.4 servings of fruits and vegetables each Activity 30.6 76.7 <5 Fruits/Vegetables Per Day day. Given this, it is quite likely that in 85.7 the near future, the state rates of 0 10 20 30 40 50 60 70 80 90 100 obesity and overweight will surpass Percent BRFSS-Behavioral Risk Factor Surveillance System (Adults 18+) that of the nation. *2002 data only available Cholesterol Screening

Sixty-six percent of Oklahoma adults Education is also associated with Cholesterol Check in Past 5 Years have had their cholesterol checked in obtaining cholesterol checks. Those by Household Income Oklahoma the past 5 years compared to 71% of the with a college degree (2003: 80%) are nation. most likely, followed by those with 100 < $50,000+ some college (2003: 73%), those with a 80 < $35,000-$49,999 Total Cholesterol Check in Past 5 Years < $25,000-$34,999 high school diploma or GED (2003: 60 by Insurance Oklahoma < $15,000-$24,999 67%), and finally, those with less than < $15,000 40 100 a high school education (2003: 61%). 20 80 Insured

0 Total 1997 1998 1999 2000 2001 2003 60 Cholesterol Check in Past 5 Years 2002 BRFSS data unavailable by Education Oklahoma 40 Uninsured The likelihood of an adult reporting he 100 20 or she had their cholesterol checked in < CollegeGraduate 80 < SomeCollege the past 5 years is also correlated with 0 Total 1997 1998 1999 2000 2001 2003 < HS/GED 2002 BRFSS data unavailable 60 household income. Those adults with a < High School household income of $50,000 or more Those with insurance (2003: 77%) are 40 were most likely (81%) to report a significantly more likely to have had 20 recent cholesterol check compared to theirs checked when compared to those 0 1997 1998 1999 2000 2001 2003 those who made $15,000-$24,999 (65%). without insurance (2003: 47%). 2002 BRFSS data unavailable

Signs and Symptoms

Time is critical to increase survival Survey results demonstrated that 94% Regarding the signs and symptoms of and decrease disabilities. of Oklahoma adults recognized chest stroke, 90% recognized sudden pain as a sign or symptom of a heart numbness or weakness; 88% sudden attack; 88% shortness of breath; 86% confusion or trouble speaking; 86% Heart Attack pain or discomfort in the arms or sudden trouble walking, dizziness or Treatment < 5 minutes of onset shoulders; 70% feeling weak, faint, or loss of balance; 65% trouble seeing in Stroke lightheaded, and 53% pain in jaw, neck one or both eyes; and 60% severe Treatment < 3 hours of onset or back. headache with no know cause. For more information on the Task Force, (continued) contact: Oklahoma CVD Facts Connie Johnson, •Oklahoma has experienced the least improvement in the Sr. Legislative Analyst—Senate cardiovascular mortality disease rate, declining by only 12.7/100,000 1-405-521-5776 population compared to 15.0/100,000 for the overall U.S. population. [email protected] •More than 25% of Oklahoma’s adult population had either high blood Marcia Goff pressure or high blood cholesterol. Researcher– House •Oklahomans with lower income are more likely to have been diagnosed 521-3201 with high blood pressure. [email protected] •African-Americans and American Indians are more likely to die from For more information on the Data heart disease in Oklahoma. subcommittee, contact : Janis Campbell, PhD Chronic Disease Division, What Now? Oklahoma State Department of Health. Given the high cost we are paying with our citizens lives, what is being done 1000 NE 10th Street, to address cardiovascular disease in Oklahoma? Currently, only $300,000 is Oklahoma City, OK 73117 being made available by the Federal Government to fund the Oklahoma 1-405-271-4072 Heart Disease and Stroke Health Program. There are no state dollars [email protected] allocated at this time. In 2004, a strategic plan was written for use as a framework to improve the This publication, printed by Docutech, was issued by the quality of care for persons and families with heart disease and stroke, to Oklahoma State Department of Health as authorized by James reduce the risk factors among all Oklahomans to prevent heart disease and M. Crutcher, MD,MPH. 1,000 copies were printed in March of 2005 at a cost of $290.00. Copies have been deposited with the stroke, to reduce the disparities in health status among persons with heart Publications Clearinghouse of the Oklahoma Department of disease and stroke, and to improve on the early recognition, action, and Libraries. healthcare response needed to reduce death and disability related to heart attack and stroke. The strategic plan provides a framework through 2010 Newsletter prepared by: with recommended action steps. Strategies have been developed that focus Health Care Information on seven over-arching goals. Division, Oklahoma State If you would like to receive more information on the strategic plan and the Department of Health specific goals, please contact Misty D. Worley at (405) 271-4072. Quality Improvement in Medicare: National Performance Measures

Acute myocardial infarction (MI) is For the first quarter of 2004, Oklahoma Acute Myocardial Infarction responsible for the death of 1.1 million was below the national rate in all four Current Surveillance, 1st Quarter 2004 Americans each year. There are measures. Rates varied, however, Oklahoma National National Benchmark* 98.4 98.1 100 93.8 93.7 90.4 400,000 Medicare hospital admissions based on the race of the individual. 87.7 80 75.4 77.2 70 65.7 annually and it is the most common Whites were more likely than either 61.8

t 60 56 n e c

cause of death. Heart failure affects 1-2 American Indians or African r e million Americans. It is responsible for Americans to receive any of the P 40 713,000 Medicare hospital admissions recommended practices. 20 annually and is the most common 0 ASA DC ACE-i LVSD Smoking �-block DC reason for hospitalization. Acute Myocardial Infarction Counseling Current Surveillance, 1st Quarter 2004 Discharge Measures National performance measures have now been implemented to ascertain Caucasian American Indian African American Administration of aspirin upon 100 93 discharge was slightly higher among how often Best Practices are utilized. 83 85 80 American Indians than Whites. African 68 For acute MIs, this includes upon 63

t 60 n Americans were most likely to receive 50 e

admission, an early administration of c r e aspirin and beta blockers and P 40 smoking counseling and Whites were 20 most likely to receive beta blockers. measuring the time until reperfusion 20 therapy. 0 ASA Admit �-block Admit Thrombolytic w/n PTCA w/n 90 Acute Myocardial Infarction 30 minutes* minutes* st Acute Myocardial Infarction Admission Measures Current Surveillance, 1 Quarter 2004 Current Surveillance, 1st Quarter 2004 Caucasian American Indian African American Oklahoma National National Benchmark* 100 98.7 98.3 100 At discharge, measures include the 96.8 86 100 83 87.7 79 80 76 80.4 81.1 administration of aspirin, ACE-I/ARB 80 66 67 63 61 60 65.7 t 60 for patients with systolic dysfunction, n e t

60 c n r e

e 40 c P r 40 e beta blockers and smoking cessation P 40 27.8 25 counseling. For the first quarter of 20 20

0 0 2004, Oklahoma was lower than the 0 0 ASA DC ACE-i LVSD Smoking �-block DC � ASA Admit -block Admit Thrombolytic w/n PTCA w/n 90 Counseling 30 minutes* minutes* national rate for all measures except Admission Measures the administration of ACE-I/ARB. Discharge Measures Assessing Health Disparities: The Oklahoma Minority Health Survey

P r o vi d e d b y : D a t a S u b c o m mi t t e e s o f t h e O k l a h o m a T a s k F o r c e t o E l i m i n a t e H e a l th D is p a r i t i e s What is the Oklahoma Minority a n d t he O k l a h o ma T u r n i n g P o in t C o u n c i l Health Survey? The Oklahoma Minority eligible, only one member Volume 1, Issue 3 Behavioral Risk Factor was selected at random to April, 2005 Survey (OMBRFS) is a be interviewed. survey that was done in In addition to the routine Oklahoma and focused questions regarding For More Information: specifically on minority health status, access to Janis E. Campbell, Ph.D. populations. Information care, and various health Surveillance Coordinator was collected using a Chronic Disease Service behaviors, other questionnaire similar to OSDH important questions were (405) 271-4072 the one used in the OK also asked to determine if [email protected] Behavioral Risk Factor minority populations Health Surveillance Derek Pate, M.P.H. acted or were treated OK BRFSS Coordinator System (BRFSS). See Health Care Information Div differently from White page 2 for details. OSDH populations. The added (405) 271-5562 The OMBRFS was questions asked about [email protected] 2003 through December conducted over the discrimination, trust, 2004. The survey took Joyce Kirksey telephone and includes language and ethnicity, Call Center Coordinator approximately 20 to 30 several initial questions and alternative medicine. Health Care Information Div minutes to complete and OSDH to identify whether or not Other questions required the help of 8 (405) 271-2838 there is anyone in the addressed sexual assault, part-time interviewers, 4 household who may be osteoporosis and BRFSS Website of which were Spanish- www.cdc.gov/brfss any racial group other deterrents to obtaining speaking. than non-Hispanic White. mammograms and pap While all Hispanic and smears. non-White members of a The OMBRFS was given household were conducted from April Inside this issue:

Discrimination in 1,3 Discrimination in Oklahoma Oklahoma BRFSS 2 Determining whether or residents whether or not they had been not patients felt they they felt like they were discriminated against, OMBRFS Response 2 were discriminated treated unfairly or with the most often cited Rates against by health care disrespect due to a reasons were related to providers, as well as variety of issues such as their health insurance What Now? 4 estimating to how this race, appearance, ability status (7.1%) and their perception varied by race, to pay, English fluency, ability to pay (5.3%). Four was of high concern to and weight. [For the of the top six categories Special Thanks 4 researchers. exact wording of the were related to money question, see page 3]. and included OMBRFS interviewers Health Outcomes: 4 asked non-White Of those who believed Continued page 3 OMBRFS vs. BRFSS Page 2 Assessing Health Disparities: The Oklahoma Minority Health Survey

Task Force Committee Behavioral Risk Factor Surveillance System Claudia Barajas Sen. Bernest Cain The Okla. Minority Behavioral Risk The Oklahoma BRFSS is an ongoing, Dr. Nancy Chu, OU Factor Health Survey is modeled after state-based survey that has been Annette Johnson, OUHSC a larger project, the Behavioral Risk conducted since 1988. This survey is Carter Anthony McBride Factor Surveillance System (BRFSS). currently being conducted in all 50 Tim O’Connor states, the District of Columbia, Puerto Maria Palacios According to the Centers for Disease Rico, Guam and many other countries. Mike Parkhurst Control and Prevention (CDC), Chester Phyffer scientific research clearly shows that Adults age 18 and older across the Brad Stanton personal health behaviors play a major state are called at random and asked Dr. Gloria Teague role in premature death and illness. In various questions related to their Rep. Opio Toure order for Oklahoma policy makers and health status, their access to health health experts to evaluate the risk our care and a range of associated risk Data Subcommittee state residents have for poor health, it behaviors. Some of these behaviors Janis Campbell, OSDH- Chair is very important that they have data include physical activity, nutrition, Spender Anthony, OHCA on actual behaviors, rather than on tobacco use, health care access, and Pam Archer, OSDH attitudes or knowledge. This type of immunization. Other questions revolve Anne Bliss, OSDH information is especially useful for around potential diagnoses that may J. Boyd, Cherokee Nation planning, initiating, supporting, and have been made by a health care Daryl Baker, OHCA evaluating health promotion and provider such as cancer, diabetes, Kelly Baker, OSDH disease prevention programs. arthritis and heart disease. Don Blose, OSDH Sen. Bernest Cain, OK State Senate Dan Cameron, IHS OMBRFS Response Rates Hannah Comstock, OSDH Joe L. Conner, Paradox A.I. Research Normally, it is very difficult to develop the state population. In the OMBRFS, Kym Cravatt, Cherokee Nation estimates of health related risk for however, less than 5 percent of the Mary Daniel, OUHSC races other than African American or respondents were White. Marcia Goff-House Staff American Indian using BRFSS due to In 2003, the BRFSS surveyed a total of Bunner Gray, Cherokee Nation the small number of individuals from 71 Asian individuals. With few Claudette Greenway, OFMQ other races who are called at random exceptions, this was much too small for Neil Hann, OSDH and who then respond to the survey. evaluation. OMBRFS, however J.Paul Keenon, OHCA The OMBRFS was specifically designed interviewed 335. Sohail Khan, IHS Sara Lassiter, House Staff to call areas that were more likely to There were 3.5 times more interviews Tracy Leeper, ODMHSAS have non-White households. OMBRFS completed by African American Peng Li, OSDH was particularly successful at Oklahomans with the OMBRFS than Wendy Montemayor, IHS accomplishing this. the BRFSS, 2.5 times more by Becki Moore, ODMHSAS American Indians and 5.5 times more In the 2003 BRFSS, 79% of the Joyce Morris, OSDH– Tobacco Use surveys completed by Hispanics. respondents were White, which is Barbara Neas, OUCOPH similar to the proportion of White in Paul Patrick-OSDH LaSahonda Phillips, Integris Health Completed Survey Comparison (Number and Percent) Anastasia Pittman, House Staff OMBRFS OK BRFSS Angela Shoffner, OHCA 2003-2004 2003 Brad Stanton, NEOCHC Carrie Tutor, OSDH African American NH 1,582 29.0% 468 6.1% Brent Wilborn, OKPCA Native American NH 1,381 25.3% 528 6.9% Kelly Walkingstick, OKQIO Asian NH 335 6.1% 71 0.9% Jeff Wallace, ODC Pacific Islander NH 27 0.5% 13 0.2% Adeline Yerkes, OSDH Other NH 53 1.0% 38 0.5% White NH 240 4.4% 6,061 79.4% First Annual Data Report– 9/04 Multi-racial 356 6.5% 169 2.2% http://www.health.state.ok.us/ Hispanic 1,476 27.1% 266 3.5% commish/HDReport2004lowres.pdf Unknown 2 0.0% 19 0.2% Other Newsletters: http://www. Total 5,452 100.0% 7,633 100.0% health.state.ok.us/commish/hd/ newsletters.html NH=Non-Hispanic Volume 1, Issue 3 Page 3

Discrimination in Oklahoma (continued) income (4.1%) as the 4th most often cited reason and Medicaid (2.1%) Survey Question coverage as the 6th. Race or ethnic background was 3rd at 4.4%. “Thinking about all of the experience you have had with health care visits in Discrimination due to sexual the last 2 years, have you ever felt that the doctor or health provider you saw orientation was cited least often (0.3%). or any other staff members judged you unfairly or treated you with disrespect because of… Perceived Reason Percent V What your race or ethnic background is. V Whether or not you have health insurance. Health Insurance 7.1 V Whether you are male or female. Pay 5.3 V How well you speak English. Race 4.4 V Whether or not you were physically disabled. Money 4.1 V How you were . Treatment 3.2 dressed or groomed V Medicaid 2.1 How much education you have. Gender 1.9 V Whether or not you were overweight. Language 1.9 V How much money you had. Disabled 1.9 V Your sexual orientation – that is, if you are gay, lesbian or have a Education 1.7 same sex partner. Dressed 1.8 V Your ability to pay for the care. Overweight 1.7 V Something in your medical history. Medical History 1.6 V The treatment you needed that day. Medicare 0.9 V Your Medicaid coverage. Gay/Lesbian 0.3 V Your Medicare coverage. One in twelve Asian residents (8.2%) felt like they had been discriminated best for them almost all or most of the against because of their race. This is Medicaid: time. Only 4% reported trusting their higher compared to 6.3% of African- doctors almost none of the time. OkMBRFS 2003-04 Americans, 3.9% of Hispanics, 2.6% of American Indians and 2.4% of Seventy percent trusted hospitals to do 9% multiracial residents. Overall 4.4% the right thing most or almost all of the reported they had been discriminated time, one in four trusted hospitals only against because of race. 30% some of the time and six percent 61% trusted hospitals almost none of the Survey Question time. This was similarly true for clinics/health centers, health Almost all or most of the time How much of the time do you think departments and Medicare. Only some of the time you can trust [Doctors or other Almost none of the time 26.1% Unknown/Refused health care providers, Hospitals: Hospitals, Clinics or Health Fewer than half (48%) trusted health Centers, County or City/County OkMBRFS 2003-04 insurance companies to do what was Health Departments, Medicare, 6% best for them all or almost all of the Medicaid, Health Insurance time. Thirty-six percent trusted them to do what is best for Companies] 24% only some of the time and one in six patients or customers? reported they almost never trusted 70% Sixty percent of non-White residents health insurance companies to do what trusted their doctors to do what was was best for patients or customers. Almost all or most of the time Health Insurance Companies: Doctors and Other HCPs: Only some of the time Almost none of the time OkMBRFS 2003-04 OkMBRFS 2003-04 4.9% Unknown/Refused

6% 16% Sixty-one percent of non-White 34% residents trusted Medicaid to do what 48% 60% was best most or almost all of the time. 36% Thirty percent trusted Medicaid only some of the time and nine percent Almost all or most of the time reported they trusted Medicaid to do Almost all or most of the time Only some of the time Only some of the time Almost none of the time what was right almost none of the time. Almost none of the time 4.8% Unknown/Refused 17.0% Unknown/Refused For more information on the Task Force, contact: What Now? Connie Johnson, Sr. Legislative Analyst—Senate 1-405-521-5776 A data CD is currently being prepared and a work group is being [email protected] organized to develop an analysis and publication plan. Marcia Goff Participants will consider how to best merge the OMBRFS with Researcher– House 521-3201 the 2003 Oklahoma BRFSS, as well as to how to interpret the [email protected] information collected from the Trust and Discrimination modules.

For more information on the Data It is hoped that culturally appropriate interventions can be subcommittee, contact : Janis Campbell, PhD developed using the OMBRFS data and that recommendation Chronic Disease Division, related to provider education can made to the Health Disparities Oklahoma State Department of Health. 1000 NE 10th Street, Task Force to lessen provider discrimination in the treatment of Oklahoma City, OK 73117 ethnic minorities. 1-405-271-4072 [email protected] If you have questions or would like to participate in the workgroup,

This publication, printed by Docutech, was issued by the please contact Janis Campbell, PhD [[email protected]] for Oklahoma State Department of Health as authorized by James M. Crutcher, MD,MPH. 1,000 copies were printed in April of 2005 more information. at a cost of $290.00. Copies have been deposited with the Publications Clearinghouse of the Oklahoma Department of Libraries. Special Thank You Newsletter prepared by: Eight part-time staff worked 6 days a Health Care Information week for 21 months interviewing state Division, Oklahoma State residents in order to collect the OMBRFS Department of Health information. Our thanks go out to them! (OMBRFS Bilingual interviewers—Left to Right: Gloria Martinez, Daniela Cavazo, Yvonne Gonzales, Adriana Alfonsin)

OMBRFS OK BRFSS Health Outcomes: 2003-2004 2003 OMBRFS vs. BRFSS DIABETES Percent S.E. Percent S.E. African American NH 9.2 1.1 9.5 1.4 The estimates provided by the Native American NH 12.3 1.1 11.3 1.4 OMBRFS were very similar to those provided by the BRFSS. This is Asian NH 5.6 2.2 ** ** important because it provides evidence Other NH * * 6.3 2.9 for the accuracy of the estimates. Not White NH * * 6.6 0.3 only will OMBRFS provide new Multi-racial 9.2 2.7 12.8 3.1 estimates for non-White groups that Hispanic 6.8 1.2 6.5 1.5 were not previously available due to HIGH BLOOD PRESSURE small numbers but it will also allow African American NH 30.6 1.9 34.9 2.6 researchers to estimate health disparities among those groups with Native American NH 31.1 1.7 29.4 2.2 greater precision than before which is Asian NH 13.3 2.9 14.3 4.3 reflected in lower standard errors (SE). Other NH * * ** ** White NH * * 29.4 0.7 What has been learned so far? Multi-racial 34.8 4.5 46.0 4.4 • Rates of diabetes and high Hispanic 14.3 1.4 14.6 2.4 cholesterol can now be calculated for HIGH CHOLESTEROL Oklahoma’s Asian population. African American NH 25.0 2.0 28.8 2.7 • American Indians rate of high blood Native American NH 36.2 2.1 26.1 2.4 pressure was significantly higher Asian NH 31.0 5.3 ** ** than that of Whites. Other NH * * ** ** White NH * * 33.5 0.8 • African-American and Hispanic rates of high cholesterol was significantly Multi-racial 39.8 5.3 41.4 4.9 lower than that of Whites. Hispanic 26.6 2.5 24.6 4.1 NH: Non-Hispanic * Excluded from analysis ** Small numbers in cell Tobacco-Related Disparities in Oklahoma

P r o vi d e d b y : D a t a S u b c o m mi t t e e o f t h e O k l a h o m a T a s k F o r c e t o Why is Tobacco Important? E l i m i n a t e H e a l th D is p a r i t i e s a n d t he O k l a h o ma T u r n i n g P o in t C o u n c i l When thinking about the average of 5,827 deaths impact smoking is having due to smoking (1997­ on Oklahoma, it is 2001). This includes 2,231 Volume 1, Issue 4 important to consider not cancer deaths, 2,078 only the number of deaths cardiovascular deaths, June, 2005 attributed to smoking and and 1,518 respiratory when people die, but also disease deaths. (Deaths the economic impact due to secondhand smoke annually due to smoking. For More Information: smoking has associated and cigarette-caused fires Approximately $1 billion ($908,000,000) are spent Joyce Morris, PhD with the treatment of were not included.) Tobacco Use Prevention smoking-related illnesses. annually on adult health There were 83,738 years care expenditures, Service To accomplish this, of life lost for each of including ambulatory OK State Dept of Health SAMMEC (Smoking those deaths that care, hospitals, 1000 NE 10th Street Attributable Mortality occurred before the age of prescription drugs, Oklahoma City, OK 73117 and Morbidity Economic 65. This included 34,156 nursing homes and other 1-405-271-3619 Costs) was developed by years of potential life lost expenditures (1998). 1-877-662-8887 (toll-free) the Office of Smoking and to cancer, 31,587 years to [email protected] Health at the U.S. cardiovascular disease, Among newborns, it was Centers for Disease and 17,995 years to estimated in 1997 that Oklahoma Tobacco Control and Prevention. respiratory disease. there was nearly six Helpline million additional dollars 1-866-PITCH-EM It has been estimated Economically, nearly $1.5 ($5,764,723) spent in 1-866-748-2436 that each year in billion ($1,462,187,000) in neonatal costs due to Oklahoma, there is an productivity are lost

Inside this issue:

Who Smokes? Why is Tobacco 1 Important?

For More Information 1 Among pregnant women, than women (24.2%) to individual reports, the one in three (31.2%) report smoking. (2004 more likely he or she is to smoked during the three BRFSS) report smoking. More Who Smokes? 1-2 months prior to their than one-third (36.5%) of Native Americans are pregnancies. Of those, those who made less than most likely to report two-thirds were still $15,000 reported smoking Health Care Provider 2 smoking (34.9%), followed Advice smoking during the last compared to 15.9% of by African Americans trimester of their those who made $75,000 (31.8%), Whites (23.4%) Who is Quitting? 3 pregnancies. One in four or more [see graph on and Hispanics (17.3%). (27%) mothers reported page 2].(2004 BRFSS) (2004 BRFSS) smoking after delivery. Data Sources 4 Education is also (2002 PRAMS) Smoking is highly associated with smoking. associated with income. Men (28.1%) are Secondhand Smoke 4 The less income an moderately more likely Continued page 2 Page 2 Tobacco-Related Disparities in Oklahoma

Task Force Committee Who Smokes? continued Claudia Barajas Sen. Bernest Cain Dr. Nancy Chu, OU More than one-third (36.6%) of adults Approximately one in three adults age Annette Johnson, OUHSC (age 18+) with less than a high school 18-54 report smoking compared to one Carter Anthony McBride diploma report smoking compared to in four (22.6%) adults age 55-64 (22.6%) Tim O’Connor 12.9% of college graduates. (2004 and one in 10 (10.9%). (2004 BRFSS) Maria Palacios BRFSS) Mike Parkhurst Youth Tobacco Use Chester Phyffer Brad Stanton Smoking Status by Education 40 31.9 Dr. Gloria Teague 40 36.6 30

31.3 t 24 Rep. Opio Toure n e

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r 20 10 Data Subcommittee e 4.9 4.2 4.8 P 12.9 Janis Campbell, OSDH- Chair 10 0 Any use Cigarettes Smokeless Cigars Pipe Spender Anthony, OHCA 0 Grades 6-8 Grades 9-12 Le ss Than H.S. H.S. or G.E.D. Some Post-H.S. Colle ge Grad Pam Archer, OSDH Anne Bliss, OSDH High school students (grades 9-12) are J. Boyd, Cherokee Nation Older adults are less likely to report more likely than middle school Daryl Baker, OHCA smoking than younger adults. students (grades 6-8) to report using Kelly Baker, OSDH tobacco, be it cigarettes, cigars, pipe or Don Blose, OSDH any tobacco. (2002 OYTS) Sen. Bernest Cain, OK State Senate Smoking Status by Age Smoking Status by Income Dan Cameron, IHS 40 Hannah Comstock, OSDH 40 36.5 32.3 32.5 34.1 29.2 29.4 Joe L. Conner, Paradox A.I. Research 30 30 t 22.6 26.5 25.8 Kym Cravatt, Cherokee Nation n e t c n

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10.9 P 10 Marcia Goff-House Staff 10 Bunner Gray, Cherokee Nation 0 18-24 25-34 35-44 45-54 55-64 65+ 0 Claudette Greenway, OFMQ Less than $15,000 $15,000 - 24,999 $25,000 - 34,999 $35,000- 49,999 $50,000 - 74,999 $75,000+ Neil Hann, OSDH J.Paul Keenon, OHCA Sohail Khan, IHS Health Care Provider Advice Sara Lassiter, House Staff Tracy Leeper, ODMHSAS Peng Li, OSDH Three of four (73.1%) new mothers BRFSS) Wendy Montemayor, IHS reported that a health professional Becki Moore, ODMHSAS Providers were most likely to talk to talked to them about smoking while Joyce Morris, OSDH– Tobacco Use smokers with mid-level incomes of they were pregnant. Health care Barbara Neas, OUCOPH $24,000-$49,999 and less likely to talk professionals were more likely to talk to Paul Patrick-OSDH to individuals with higher incomes. smokers than non-smokers. Those LaSahonda Phillips, Integris Health (2003 BRFSS) women whose doctors were less likely Anastasia Pittman, House Staff to talk to them were older (age 35+), Three of four smokers with a high Angela Shoffner, OHCA were better educated (more than a high school diploma reported receiving Brad Stanton, NEOCHC school education), or did not use advice about smoking compared to Carrie Tutor, OSDH Medicaid to pay for their delivery. 70.0 % of those with less than a H.S. Brent Wilborn, OKPCA (2002 PRAMS) diploma, 67.6% of those with some post­ Kelly Walkingstick, OKQIO H.S. courses, and 65.7% of college Jeff Wallace, ODC Among adult smokers who received graduates. (2003 BRFSS) Adeline Yerkes, OSDH medical care in the past 12 months, Providers were more likely to offer health care providers were more likely First Annual Data Report– 9/04 to provide advice about smoking to advice as smokers got older. Fifty-seven http://www.health.state.ok.us/ women (72.9%) than men (66.3%). percent of smokers between 18 and 24 commish/HDReport2004lowres.pdf Native Americans were more likely to years of age reported receiving advice report receiving advice (76.0%) than compared to 77% of those age 55 to 64. Other Newsletters: http://www. Whites (68.9%), African Americans This decreased to 69% among those age health.state.ok.us/commish/hd/ (68.5%) or Hispanics (64.3%). (2003 65 or older. (2003 BRFSS) newsletters.html Volume 1, Issue 4 Page 3

Who is Quitting?

Male smokers (59.4%) were more likely Smokers Who Quit Smoking half of the callers reported income less than female smokers (55.0%) to report 1+ Days Last Year less than $20,000. Five percent of that they had quit smoking for at least callers reported having incomes of more 70 by Age one day during the last year. (2004 59.4 than $40,000. A significant number (1 60 55 BRFSS) 52.8 51.8 in 6) did not disclose their income to 50 46.4

t 39.8 n

e 40 the helpline. (8/03-3/05 OUHSC) c Three of five Hispanic (63.5%) and r e 30 P African American (61.3%) smokers 20 report they tried to quit for at least one 10 Registered Tobacco Helpline 0 day last year compared to 52.6% of 18-24 25-34 35-44 45-54 55-64 65+ Callers by Income Native Americans. White smokers were 35 29.8 least likely to have attempted to quit 30 Among middle and high school 25.6 (49.1%). (2004 BRFSS) 25 t

students, African American youth were n e 20 16.5 c 15.3 r

There was no clear association between e 15 more likely to have attempted cessation P 10 7.1 attempting to quit and income. compared to White, Hispanic or other 4.9 5 0.8 Reported attempts to quit ranged from youth. (2002 OYTS) 0 43% among those with an income of None < $10,000 $10,000- $20,000- $30,000- $40,000+ Unk With the exception of the White youth, $19,999 $29,999 $39,999 less than $15,000 to 67% among those high school students were more likely with an income between $25,000 and to have tried to quit. Rates were very Two-thirds of callers were either H.S. $34,999. (2004 BRFSS) similar between high school and middle graduates or had additionally attended Smokers Who Quit Smoking school Hispanic youth. (2002 OYTS) some college or vocational school. 1+ Days Last Year Twenty percent of callers had less than by Income Youth Tried to Quit Past Year a high school education and less than 70 100 8% were college graduates or higher. 54.9 57.0 60 50.8 53.8 80.5 47.0 74.9 (8/03-3/05 OUHSC) 50 43.2 80 68.9 t 62.3 62.2 n t 59.8 60.1 59.6 e

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30 r P e 40 20 P Registered Tobacco Helpline 10 20 0 Callers by Education Less than $15,000 - $25,000 - $35,000 - $50,000 - $75,000+ 0 $15,000 24,999 34,999 49,999 74,999 White African Hispanic Other 40 37.0 American 28.5 Grades 6-8 Grades 9-12 30 t n e c

Smokers with less than a high school r 20 13.5

A tobacco helpline was established in P e education were less likely to try to stop August 2003 and the University of 10 7.2 6.6 6.2 than those with more education. 1.0 Oklahoma Health Sciences Center 0 Smokers with some post H.S. education < High Some HS Some College Graduate Unk College of Public Health was contracted School High graduate Coll/Voc Graduate School (59.6%) were most likely to report they School School to conduct a survey of the callers. had tried to quit during the past year. (2004 BRFSS) Registered Tobacco Helpline The age of callers to the helpline Callers by Race/Ethnicity Smokers Who Quit Smoking spanned all groups. The fewest calls 80 75.1 1+ Days Last Year came from the youngest (18-19) and the 60 oldest (70-79) and peaked among t

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P White African American Other Unknown Hispanic 20 American Indian 10 Registered Tobacco Helpline 0 Two-thirds of callers to the registered Less Than H.S. H.S. or G.E.D. Some Post-H.S. College Grad Callers by Age tobacco helpline were women (65.2%). 30 These individuals spoke to a tobacco 25.9

specialist and/or received a self-help 19.6 20 18.8 Younger smokers were most likely to t 17.4 n

kit. Three of four callers were White. e c have attempted to quit in the past year. r e

(8/03-3/05 OUHSC) P 9.5 Three in five (59.4%) of smokers age 18­ 10 2.7 24 tried compared to 39.8% of those age Thirty percent of the callers reported 1.3 0 65 or older. (2004 BRFSS) less than $10,000 income. More than 18-19 20-29 30-39 40-49 50-59 60-69 70-79 For more information on the Task Force, contact: Secondhand Smoke Exposure Connie Johnson, Sr. Legislative Analyst—Senate 1-405-521-5776 In 2004, 70% of adults reported that [email protected] Home smoking bans were relatively no smoking was allowed inside their consistent across all age groups. Rates Marcia Goff home (69.2% males, 71.4% females). ranged from 66.1% among adults age Researcher– House (2004 BRFSS) 45-54 to 74.8% among those aged 25 521-3201 to 34. (2004 BRFSS) [email protected] Hispanic adults were most likely to For more information on the Data report home smoking bans (83.9%) No Smoking Inside the Home Subcommittee, contact : followed by 70.9% of Whites, 59.9% by Respondent Age

Janis Campbell, PhD 80 74.8 of Native Americans and 57.8% of 71.9 70.4 70.4 Chronic Disease Division 66.1 68.5 African Americans. 60 t n

Oklahoma State Department of Health e c

r 40 e 1000 NE 10th Street P No Smoking Inside the Home 20 Oklahoma City, OK 73117 by Respondent Race/Ethnicity 0 1-405-271-4072 18-24 25-34 35-44 45-54 55-64 65+

[email protected] 100 83.9 80 70.9 High school students were more likely This publication, printed by Docutech, was issued by the 59.9 t 57.8 to report they had been in a room with Oklahoma State Department of Health as authorized by n 60 e c

James M. Crutcher, MD,MPH. 1,000 copies were printed r

e someone who was smoking during the in June of 2005 at a cost of $290.00. Copies have been P 40 deposited with the Publications Clearinghouse of the past week than middle school students. 20 Oklahoma Department of Libraries. This was most common among 0 White African American Native American Hispanic students who were either White or Newsletter prepared by: “Other” race. African American Health Care Information Home smoking bans were more likely Division, Oklahoma State students were least likely to report Department of Health to occur among individuals with recently being in the room with a higher household incomes. Adults smoker. (2002 OYTS) with less than $15,000 were least Data Sources likely to report there was no smoking Youth in Room with Smoker allowed in their homes (58.4%) During the Past Week compared to 86.1% of adults with Data for this report was compiled from by Race/Ethnicity and School Level household incomes of $75,000 or 80 74.1 72.5 74.5 a variety of sources that collect the in­ 61.6 more. 56.1 59.6 formation in very different ways. 60 49.8 51.5 • Behavioral Risk Factor Surveil­ No Smoking Inside the Home 40 lance System (BRFSS) - telephone by Household Income 20 • Pregnancy Risk Assessment Moni­ 0 100 86.1 Grades 6-8 Grades 9-12 79 72.4 toring System (PRAMS) - mail 80 70.3 White African American Hispanic Other t 58.4 59.8 n 60 e

c • Oklahoma Tobacco Helpline ­ r

e 40

P Eighty-three percent of women report telephone 20 their worksites have a no-smoking • Oklahoma Youth Tobacco Survey 0 LessThan $15,000- $25,000- $35,000- $50,000- Greater policy compared to 73% of men. This (OYTS) - school based $15,000 24,999 34,999 49,999 74,999 Than $75,000 is most common among White adults Concerns were expressed at an earlier (80.5%) compared to 76.5% of Native task force meeting about the efficacy of Smoking bans in the home were more Americans, 70.3% of African telephone surveys and whether all ra­ likely to be reported by those with Americans and 69.5% of Hispanics. cial groups were equally represented higher educations. College graduates given not all households have a phone. were most likely to report banning No-smoking policies were reported The 2000 Census estimated more than smoking (82.9%) compared to 56.9% more often by adults with higher 90% of all households had a telephone of those with less than a high school household incomes and ranged from available. This figure ranged from education. 70.6% among those with incomes of 87.9% among those of the “Other” race less than $15,000 up to 86.2% among to 97.8% of the Asian/Pacific Islander race. No Smoking Inside the Home those with incomes of $75,000 or by Respondent Education more. Smoking bans at work increased Household Telephone Available 100 82.9 with age and adults with less than a by Race/Ethnicity of Householder 80 73.7 63.2 high school education (64.3%) were

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20 0 graduates. (2004 BRFSS) Less Than HS HS/GED Some post HS College grad 0 White African Native API Other Two or more Hispanic American American This publication was printed and issued by the Oklahoma State Department of Health, as authorized by James M. Crutcher, MD, MPH, Commissioner of Health. 200 copies were printed by the Oklahoma State Department of Health at a cost of $2500. Copies have been deposited with the Publications Clearinghouse of the Oklahoma Department of Libraries.

36 Oklahoma Task Force to Eliminate Health Disparities • Data Report 2004