Jewish Hospital – Community Health Needs Assessment

Community Health Needs Assessment FY 2013

This document includes reports for these KentuckyOne Health acute care facilities:

Continuing Care Hospital

Flaget Memorial Hospital

Frazier Rehab Institute

Jewish Hospital

Jewish Hospital Shelbyville

Our Lady of Peace

Saint Joseph Berea

Saint Joseph Hospital

Saint Joseph East

Saint Joseph London

Saint Joseph Martin

Saint Joseph Mount Sterling

Sts. Mary & Elizabeth Hospital

University of Louisville Hospital and James Graham Brown Cancer Center

A report is also included for Southern Indiana Rehab Hos- pital, a joint venture of Ken- tuckyOne and Floyd Memorial and Clark Memorial Hospitals.

Foreword

IRC Section 501(r) requires health care organizations to assess the health needs of their communities and adopt implementation strategies to address identified needs. To comply with the Affordable Care Act and federal tax-exemption requirements, a tax-exempt hospital facility must:

Conduct a community health needs assessment every three years. Adopt an implementation strategy to meet the community health needs identified through the assessment. Report how it is addressing the needs identified in the community health needs assessment and a description of needs that are not being addressed with the reasons why such needs are not being addressed.

The community health needs assessment must take into account input from people who represent the broad interest of the community served by the hospital facility, including those with special knowledge of or expertise in public health. The hospital facility must make the community health needs assessment widely available to the public.

This community health needs assessment, which is both a document and a description of a process, is intended to document how KentuckyOne Health hospitals are in compliance with IRC Section 501(r). The health needs of each community have been identified and prioritized so that each hospital may adopt an implementation plan to address specific needs of the community it serves. Furthermore, statewide trends and common themes have been identified so that the strength, breadth, and depth of KentuckyOne Health can be leveraged to create measurable health improvement.

Community Health Needs Assessment 2013

Contents

Introduction ...... 1

Executive Summary ...... 1 Organization Description ...... 3

How the Assessment was Conducted...... 5

Community Served by the Hospital ...... 6

Identification and Description of Geographical Community ...... 6 Defined Community or Service Area ...... 6 Community Population and Demographics ...... 9 Socioeconomic Characteristics of the Community ...... 11 Income, Poverty and Unemployment ...... 12 Uninsured Status ...... 13 Education...... 14 Community Health Care Resources ...... 14 Hospitals ...... 15 Ambulatory Care Clinics ...... 16 Other Licensed Facilities ...... 16 Health Departments ...... 16

Health Status of the Community ...... 18

Leading Causes of Death ...... 19 Primary Health Conditions Responsible for Inpatient Hospitalization ...... 20

Health Outcomes and Factors...... 21

Health Statistics and Rankings ...... 21

Primary Data ...... 24

Community Input-Surveys ...... 24 Key Themes Provided Through Participant Comments ...... 27 Health Issues of Uninsured Persons, Low-Income Persons and Minority Groups ...... 28 Violence in the Community ...... 30

Community Health Needs Assessment 2013

Contents (continued)

Priority Community Health Needs Identified ...... 31

Appendices ...... 34

Appendix A: 2012 Louisville Metro Health Status Report Appendix B: 2012 LMPHW 2012 Community Health Needs Assessment Survey Results Appendix C: 2012 LMPHW Public Survey Appendix D: 2011 Louisville Metro Health Equity Report Appendix E: Analysis of Health Information and Primary Data Appendix F: Acknowledgements Appendix G: Sources

Community Health Needs Assessment 2013

Introduction

During 2012, a community health needs assessment was conducted by Jewish Hospital to support its mission to enhance the health of people in the communities it serves, to comply with the Patient Protection and Affordable Care Act of 2010 and federal tax-exemption requirements, and to identify health needs of the community to help prioritize the allocation of hospital resources to meet those needs. Based on current literature and other guidance from the Treasury and IRS, the following steps were completed as part of the community health needs assessment:

The ―community‖ served by was defined utilizing inpatient data on patient origin. This process is further described in Community Served by the Hospital. Population demographics and socioeconomic characteristics of the community were gathered and reported using various sources (see references in Appendices). The health status of the community was then reviewed. Information on the leading causes of death and morbidity was analyzed in conjunction with health outcomes and factors reported for the community by CountyHealthrank- ings.org. Health factors with significant opportunity for improvement were noted. An inventory of health care facilities and resources was prepared. Through a collaborative process conducted by the Louisville Metro Department of Public Health & Wellness, community input was obtained through a series of four public forums public held across the county, one forum for community leaders and medical professionals, and through an online survey.

Executive Summary Jewish Hospital identified community health needs by undergoing an assessment process in collaboration with the Louisville Metro Department of Public Health and Wellness (LMDPHW), the Kentucky Hospital Association and other Louisville area health systems (Baptist Hospital East, Norton Healthcare and University of Louisville Hospital). More than 1,800 residents provided input via community forums conducted in all four quadrants of Jefferson County and through an on-line survey (available in both English and Spanish). Another 40 community leaders, physicians, and other health professionals shared their expertise at a special community forum. In addition, secondary data was compiled from demographic and socioeconomic sources as well as national, state and local sources of information on disease prevalence, health indicators, health equity and mortality.

This was analyzed and reviewed to identify health issues of uninsured persons, low-income persons and minority groups, and the community as a whole. Health needs were prioritized utilizing a method that weighs: 1) the impact on vulnerable populations; 2) the importance to the community; 3) the size of the problem; 4) the seriousness of the problem; 5) prevalence of common themes; 6) how closely the need aligns with the strategies and strengths of the hospital and KentuckyOne Health; and 7) an evaluation of existing hospital programs responding to the identified need. The hospital engaged BKD, LLP to assist with compiling secondary data and prioritizing identified health needs.

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Subsequently, Jewish Hospital leadership entered into a dialogue with other key community partners, including representatives of LMDPHW, to discuss the results of the evaluation and select health priorities. Participants were given the opportunity to revise rankings and debate issues until a consensus was reached on a composite ranking of health issues. The process identified the following issues with scores of 14 or more (on a scale of 28): Stroke/cerebrovascular disease Access to care Chronic diseases in vulnerable neighborhoods (defined Brain disorders (mental/emotional health) by health outcomes, race and socieo-economic Shortage of primary care physicians status) Violent crime Chronic lower respiratory disease Limited access to healthy foods Cancer Addiction/substance abuse Adult obesity Adult smoking Heart disease Limited health knowledge and health education Physical inactivity

With an understanding that collaborative efforts have the greatest opportunity for measurable, collective impact, Jewish Hospital has mapped these needs to the health improvement efforts of the Mayor’s Healthy Hometown Movement which envisions a community-wide culture where healthy eating and active living are the norm and fosters an environment that promotes increased physical activity, better nutrition, healthy public policy and access to needed resources.

Mayor’s Health Hometown Priority Correlated Community Health Need

Tobacco Control and Prevention Adult Smoking

Chronic Diseases in Vulnerable Neighborhoods Adult Obesity Heart Disease Healthy Eating and Active Living Physical Inactivity

Limited Health Knowledge/Health Education Limited Access to Healthy Foods Stroke/Cerebrovascular Disease Chronic Lower Respiratory Disease Cancer Chronic Disease Prevention and Heart Disease Management Mental or Emotional Health Addiction/Substance Abuse Chronic Diseases in Vulnerable Neighborhoods Access to Services (Addressing Health Access to Care Shortage of Primary Care Physicians Disparities) Violent Crime

Jewish Hospital will continue to work with the community to execute an implementation plan to realize goals to address these identified health needs.

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Community Health Needs Assessment 2013

Organization Description

Jewish Hospital opened in 1905 with a mission to provide all patients with the highest quality care and a strong emphasis on research and education. Today, it is a 462-bed, internationally renowned, high-tech ter- tiary referral center located in downtown Louisville, developing leading-edge advancements in hand and microsurgery, heart and lung care, cancer care, home care, rehab medicine, sports medicine, orthopaedics, neuroscience, occupational health, organ transplantation, and outpatient and primary care.

Jewish Hospital is at the vanguard of medical science. It is among a select group of hospitals performing heart, lung, liver, kidney, and pancreas transplantation. It was the site of the world’s first successful hand transplant, the world’s first and second successful Ab- ioCor® Implantable Replacement Heart procedures, and world’s first trial of cardiac stem cells in chronic heart failure.

Many of Jewish Hospital’s clinical programs have achieved national rankings for excellence. In 2011, Jewish Hospital received the American Stroke Association’s Get With The Guidelines–Stroke Silver Plus Performance Achievement Award. The award recognizes commitment and success in implementing a higher standard of stroke care by ensuring that stroke patients receive treatment according to nationally accepted standards and recommendations. Jewish Hospital earned the Anthem Blue Cross and Blue Shield Blue Distinction Award for Hip, Knee and Spine Surgery, recognizing the experience and training of the program’s surgeons, the quality management programs, integrated care and patient education. Jewish Hospital also received the KODA Tissue Donation Performance Award and was ranked first in Louisville in the U.S. News & World Report’s best hospitals metro area ranking.

In 2010, Jewish Hospital opened the Center for Advanced Heart Failure and Cardiothoracic Transplanta- tion, a one-stop location for patients experiencing heart failure. Patients can learn about clinical trials, ventricular assist devices, transplantation options and other treatments, and visit with a physician and clinical coordinator.

Community partnerships are essential to Jewish Hospital. This includes working with the Kentucky Science Center and Greater Louisville Medical Society to offer Pulse of Surgery, a program that broad- casts live heart surgeries to the Science Center for school groups to learn about wellness and potential health care careers. It is addressing the epidemic of teen dating violence in partnership with the Center for Women and Families, and promoting health equity through ―Upstream to Equity,‖ a collaboration with Louisville’s Health Department, Center for Health Equity and the Network Center for Community Change.

Jewish Hospital is part of KentuckyOne Health, one of the largest health systems in Kentucky with more than 200 locations including hospitals, outpatient facilities and physician offices, and more than 2,325 li-

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censed beds. An 18-member volunteer board of directors governs KentuckyOne Health, its facilities and operations, including Jewish Hospital, with this mission:

Our Purpose To bring wellness, healing and hope to all, including the underserved.

Our Future To transform the health of communities, care delivery and health care professions so that individuals and families can enjoy the best of health and wellbeing.

Our Values Reverence: Respecting those we serve and those who serve. Integrity: Doing the right things in the right way for the right reason. Compassion: Sharing in others’ joys and sorrows. Excellence: Living up to the highest standards.

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How the Assessment was Conducted

Jewish Hospital is part of KentuckyOne Health which collaborated with the Louisville Metro Department of Public Health and Wellness (LMDPHW), the Kentucky Hospital Association and other Louisville area hospitals to conduct the Community Health Needs Assessment. Other hospital systems that participated included: Baptist Hospital East, Norton Healthcare and University of Louisville Hospital.

Four community forums were held in March 2012 at sites in each quadrant of Jefferson County. Members of the general public were asked to complete a survey on their perceptions of the city’s health care needs. The survey was available in English and Spanish and covered a broad range of topics from access to health care to perception about the most pressing health care needs. After the forums, the same survey was made available online at the LMDPHW website from March 18 to June 1, again both in English and Spanish. A total of 1,871 individuals completed the survey with demographics that closely correspond to that of Jef- ferson County: 80 percent of respondents were white, 16 percent were African-American and the remainder were Asian, Native Hawaiian, Pacific Islander and American Indiana, Alaskan Native or other. Three percent were ages 18-24, 18 percent were 25-34, 22 percent were 35-44, 28 percent were 45-54, 24 percent were 55-64 and 5 percent were age 65 or older. Respondents came from each of the city’s zip codes, with most responses from southwest Louisville.

A fifth forum was conducted by LMDPHW Director Dr. LaQuandra Nesbitt on March 29, 2012 at the Greater Louisville Medical Society tailored to gather input from community leaders, physicians and other health professionals. It was attended by 40 individuals representing a wide array of expertise including Bill Wagner, Executive Director of the Family Health Centers, Inc., Jay Davidson, Executive Director of The Healing Place, and leaders from an array of health and human service agencies that serve low-income and minority populations. The appendix includes a list detailing the organizations represented at this forum as well as the survey tool for this group and the general public.

In addition, secondary data was compiled from demographic and socioeconomic sources as well as national, state and local sources of information on disease prevalence, health indicators, health equity and mortality. The hospital engaged BKD, LLP to assist with compiling secondary data and prioritizing identified health needs.

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Community Served by the Hospital

Identification and Description of Geographical Community

Louisville is a major city—the largest in the state of Kentucky and the county seat of Jefferson County. As of 2010, the Louisville metropolitan area (MSA) had a population of 1,307,647 ranking it 42nd in size nationally. The metro area includes Louisville-Jefferson County and 12 surrounding counties, eight in Ken- tucky and four in Southern Indiana. Louisville is southeasterly situated along the border between Kentucky and Indiana, the Ohio River, in north-central Kentucky at the Falls of the Ohio. The Louisville metropolitan area is often referred to as Kentuckiana because it includes counties in Southern Indiana.

Defined Community or Service Area

A community is defined as the geographic area from which a significant number of the patients utilizing hospital services reside. While the community health needs assessment considers other types of health care providers, hospitals are the single largest provider of acute care services. For this reason, the utilization of hospital services provides the clearest definition of the community.

Jewish Hospital defines its service area for this community health needs assessment based on where the majority of its inpatients reside. Based on the patient origin of inpatient discharges from July 1, 2011 to June 30, 2012, management has identified the community as listed on Exhibit 1. It is followed by a map showing Jewish Hospital’s geographic location and the footprint of the community identified in Exhibit 1 which includes Jefferson, Bullitt, Nelson and Shelby Counties. The map displays the hospital’s defined community, identifies the zip codes that comprise this community, and illustrates its geographic relationship to surrounding counties, significant roads and highways. A demographic snapshot for these zip codes is provided in Exhibit 2 and these zip codes are listed with additional corresponding demographic information in Exhibits 3 through 8.

When specific information is not available by zip code, this community health needs assessment relies on county-level data.

Because almost 60 percent of Jewish Hospital’s inpatient discharges originate in Jefferson County, it collaborated with the Louisville Metro Department of Public Health & Wellness in conducting its community health needs assessment. Bullitt, Nelson, and Shelby Counties are served by Jewish Hospital Medical Center South, Jewish Hospital Shelbyville and Flaget Memorial Hospital, respectively. Jewish Hospital Shelbyville and Flaget Memorial are inpatient facilities which conducted their own community health needs assessments in conjunction with the county health department and with input from area residents.

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Exhibit 1 Jewish Hospital CHNA Community Summary of Inpatient Discharges by Zip Code (Descending Order) 7/1/11- 6/30/12

Percent of Total Zip Code City County Discharges Discharges

40211 Louisville, KY Jefferson 912 5.6% 40203 Louisville, KY Jefferson 770 4.7% 40216 Louisville, KY Jefferson 701 4.3% 40212 Louisville, KY Jefferson 695 4.2% 40165 Shepherdsville, KY Bullitt 579 3.5% 40229 Louisville, KY Jefferson 540 3.3% 40210 Louisville, KY Jefferson 532 3.2% 40272 Louisville, KY Jefferson 524 3.2% 40219 Louisville, KY Jefferson 503 3.1% 40214 Louisville, KY Jefferson 465 2.8% 40065 Shelbyville, KY Shelby 353 2.2% 40004 Bardstown, KY Nelson 344 2.1% 40258 Louisville, KY Jefferson 324 2.0% 40215 Louisville, KY Jefferson 301 1.8% 40218 Louisville, KY Jefferson 278 1.7% 40202 Louisville, KY Jefferson 275 1.7% 40206 Louisville, KY Jefferson 247 1.5% 40220 Louisville, KY Jefferson 218 1.3% 40299 Louisville, KY Jefferson 218 1.3% 40291 Louisville, KY Jefferson 215 1.3% 40205 Louisville, KY Jefferson 204 1.2% Other Jefferson 1894 11.6% Other Bullitt 284 1.7% Other Nelson 250 1.5% Other Shelby 117 0.7% All Other 4,639 28.3%

16,382 100.0%

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Community Population and Demographics Jewish Hospital’s primary service area is comprised of four counties: Jefferson, Bullitt, Nelson and Shelby. Almost 60 percent of the hospital’s discharges came from Jefferson County. Exhibit 2 shows the demographics and socioeconomic characteristics of Jewish Hospital’s primary service area for the most recent period available.

Exhibit 2 2012 Demographic Snapshot Jewish Hospital

DEMOGRAPHIC CHARACTERISTICS Selected Area USA 2013 2018 % Change 2000 Total Population 552,751 281,421,942 Total Male Population 292285 301200 3.05% 2013 Total Population 604,587 314,861,807 Total Female Population 312302 320507 2.63% 2018 Total Population (est) 621,707 325,322,277 % Change 2013 - 2018 2.83% 3.32% Average Household Income 2013 51,814 69,637

POPULATION DISTRIBUTION HOUSEHOLD INCOME DISTRIBUTION Age Distribution Income Distribution % of % of USA 2013 % of USA 2013 Age Group 2013 Total 2018 Total % of Total 2013 Household Income HH Count Total % of Total 0 -14 121,709 20.13% 125,531 20.19% 19.63% <$15K 44,196 18.00% 13.81% 15 - 17 23,789 3.93% 23,771 3.82% 4.11% $15 - 25K 34,707 14.13% 11.58% 18 - 24 54,486 9.01% 54,577 8.78% 9.96% $25 - 50K 70,766 28.82% 25.29% 25 - 34 81,869 13.54% 78,701 12.66% 13.08% $50 - 75K 44,057 17.94% 18.11% 35 - 54 164,715 27.24% 161,554 25.99% 26.93% $75 - 100K 25,052 10.20% 11.73% 55 - 64 76,175 12.60% 82,092 13.20% 12.37% Over $100k 26,808 10.92% 19.48% 65+ 81,844 13.54% 95,481 15.36% 13.93% Total 604,587 1 621,707 100.00% 100.01% Total 245,586 100.00% 100.00%

RACE/ETHNICITY Race/Ethnicity Distribution % of USA Race/Ethnicity 2013 Pop. Total % of Total White Non-Hispanic 410,652 67.92% 62.31% Black Non-Hispanic 136,884 22.64% 12.28% Hispanic 32,070 5.30% 17.33% Asian & Pacific Island Non-Hispanic 10,047 1.66% 5.13% All Others 14934 2.47% 2.94% Total 604,587 100.00% 100.00%

Includes: KY County of Jefferson Source: The Nielsen Company The U.S. Census Bureau has compiled population and demographic data based on the 2010 census. The Nielson Company, a firm specializing in the analysis of demographic data, has extrapolated this data to estimate population trends from 2013 through 2018.

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Exhibit 3 illustrates that the overall population is projected to increase slightly over a five-year period from 604,587 in 2013 to 621,707, a 2.8 percent increase. However, the people who utilize health care services the most, those ages 65 years and over, are projected to increase 16.7 percent, from 81,844 to 95,481. The projected change to the composition of the total community of males and females is projected to remain approximately the same over the five-year period.

Exhibit 3 Jewish Hospital CHNA Community Estimated 2013 Population Median Age Under 15-44 45-64 65 years of Total Zip Code City County 15 years years years and over Total Population Male Female

40211 Louisville, KY Jefferson 5,278 8,476 5,908 2,971 22,633 35.5 10,219 12,414 40203 Louisville, KY Jefferson 4,645 8,888 4,904 2,446 20,883 33.4 10,456 10,427 40216 Louisville, KY Jefferson 8,048 15,922 11,964 6,251 42,185 39.6 20,039 22,146 40212 Louisville, KY Jefferson 3,937 6,707 4,726 2,132 17,502 36.0 8,395 9,107 40165 Shepherdsville, KY Bullitt 6,509 12,730 9,563 4,130 32,932 38.6 16,338 16,594 40229 Louisville, KY Jefferson 8,063 15,693 9,024 4,003 36,783 35.6 18,174 18,609 40210 Louisville, KY Jefferson 3,364 5,878 3,821 1,811 14,874 34.0 6,762 8,112 40272 Louisville, KY Jefferson 7,522 13,943 9,876 5,335 36,676 38.2 17,819 18,857 40219 Louisville, KY Jefferson 7,542 14,748 9,400 5,460 37,150 37.5 17,991 19,159 40214 Louisville, KY Jefferson 9,642 19,090 12,225 6,068 47,025 36.6 23,032 23,993 40065 Shelbyville, KY Shelby 6,210 11,397 7,589 3,900 29,096 37.4 14,064 15,032 40004 Bardstown, KY Nelson 6,324 11,246 7,730 3,611 28,911 36.8 13,987 14,924 40258 Louisville, KY Jefferson 5,365 10,385 7,168 3,883 26,801 38.4 12,906 13,895 40215 Louisville, KY Jefferson 5,013 8,785 5,563 2,217 21,578 34.1 10,322 11,256 40218 Louisville, KY Jefferson 6,564 12,783 7,733 3,996 31,076 35.5 14,812 16,264 40202 Louisville, KY Jefferson 647 2,697 1,747 512 5,603 38.3 3,278 2,325 40206 Louisville, KY Jefferson 2,787 8,466 5,306 2,854 19,413 39.0 9,453 9,960 40220 Louisville, KY Jefferson 5,453 12,821 8,918 5,869 33,061 40.7 15,740 17,321 40299 Louisville, KY Jefferson 8,047 14,769 11,403 5,462 39,681 39.7 19,326 20,355 40291 Louisville, KY Jefferson 7,429 14,720 10,214 5,033 37,396 38.3 18,053 19,343 40205 Louisville, KY Jefferson 3,320 9,146 6,962 3,900 23,328 42.2 11,119 12,209 PROVIDER SERVICE AREA 121,709 239,290 161,744 81,844 604,587 292,285 312,302

PROVIDER SERVICE AREA (Projected 2018 Population) 125,531 239,201 161,494 95,481 621,707 301,200 320,507 Source: The Nielsen Company

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Exhibit 4 shows the population of the community by race by illustrating three different categories: white, black and other residents. In total, the population breakdown for the community shows a higher percentage of black residents compared to the state of Kentucky and the United States. A review of specific zip code areas shows a relatively large percentage of black residents in several zip codes representing the highest discharges from Jewish Hospital.

Exhibit 4 Jewish Hospital CHNA Community Estimated 2013 Population vs Projected 2018 Population With Percent Difference Estimated 2013 Projected 2018 Percent Total Zip Code City White Black Other Total White Black Other Total White Black Other

40211 Louisville, KY 843 21,137 653 22,633 904 21,038 764 22,706 4.0% 92.7% 3.4% 40203 Louisville, KY 7,268 12,612 1,003 20,883 7,472 12,601 1,131 21,204 35.2% 59.4% 5.3% 40216 Louisville, KY 24,071 15,922 2,192 42,185 22,723 17,869 2,577 43,169 52.6% 41.4% 6.0% 40212 Louisville, KY 6,294 10,623 585 17,502 6,049 10,774 674 17,497 34.6% 61.6% 3.9% 40165 Shepherdsville, KY 31,781 237 914 32,932 32,567 279 1,058 33,904 96.1% 0.8% 3.1% 40229 Louisville, KY 32,412 2,576 1,795 36,783 33,457 3,192 2,115 38,764 86.3% 8.2% 5.5% 40210 Louisville, KY 1,780 12,527 567 14,874 1,936 12,255 677 14,868 13.0% 82.4% 4.6% 40272 Louisville, KY 33,369 1,656 1,651 36,676 33,881 1,905 1,904 37,690 89.9% 5.1% 5.1% 40219 Louisville, KY 24,672 8,442 4,036 37,150 24,151 9,164 4,730 38,045 63.5% 24.1% 12.4% 40214 Louisville, KY 33,370 7,563 6,092 47,025 32,492 8,796 7,003 48,291 67.3% 18.2% 14.5% 40065 Shelbyville, KY 23,783 2,423 2,890 29,096 25,188 2,342 3,560 31,090 81.0% 7.5% 11.5% 40004 Bardstown, KY 25,783 1,946 1,182 28,911 27,040 1,910 1,410 30,360 89.1% 6.3% 4.6% 40258 Louisville, KY 22,420 3,241 1,140 26,801 22,210 3,939 1,351 27,500 80.8% 14.3% 4.9% 40215 Louisville, KY 12,343 7,227 2,008 21,578 11,422 7,765 2,308 21,495 53.1% 36.1% 10.7% 40218 Louisville, KY 15,935 11,906 3,235 31,076 15,761 12,116 3,843 31,720 49.7% 38.2% 12.1% 40202 Louisville, KY 1,981 3,281 341 5,603 2,160 3,159 369 5,688 38.0% 55.5% 6.5% 40206 Louisville, KY 16,364 1,877 1,172 19,413 16,395 1,813 1,258 19,466 84.2% 9.3% 6.5% 40220 Louisville, KY 25,503 4,948 2,610 33,061 25,061 5,431 2,989 33,481 74.9% 16.2% 8.9% 40299 Louisville, KY 33,906 3,459 2,316 39,681 35,028 3,875 2,687 41,590 84.2% 9.3% 6.5% 40291 Louisville, KY 30,681 4,441 2,274 37,396 31,707 5,259 2,734 39,700 79.9% 13.2% 6.9% 40205 Louisville, KY 21,878 602 848 23,328 21,909 626 944 23,479 93.3% 2.7% 4.0%

PROVIDER SERVICE AREA 426,437 138,646 39,504 604,587 429,513 146,108 46,086 621,707 69.1% 23.5% 7.4%

Kentucky (1,000s) 3,769 342 293 4,404 3,815 354 342 4,511 84.6% 7.8% 7.6% U.S. (1,000s) 196,201 38,662 79,999 314,862 195,933 40,292 89,098 325,322 60.2% 12.4% 27.4%

Source: The Nielsen Company

Socioeconomic Characteristics of the Community

The socioeconomic characteristics of a geographic area influence the way residents access health care services and perceive the need for them. The economic status of an area may be assessed by examining multiple variables within the community. The following exhibits are a compilation of data that includes household income, poverty, unemployment rates and educational attainment for the community served by the hospital. These standard measures will be used to compare the socioeconomic status of the counties served internally as well as to the state.

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Income, Poverty and Unemployment

Exhibit 5 presents the median household income and median age in each zip code. Median household incomes range from $15,937 to $63,437. Shaded zip codes have median household income below the federal poverty level for a family of four. These same zip codes have percentages of population in poverty and unemployment rates that are unfavorable compared to state and national averages.

Exhibit 5 Jewish Hospital CHNA Community Median Household Income, Poverty and Unemployment Rates of Community Estimated 2013 Median Population Household in Unemployment Zip Code City State County Income Poverty Rate

40211 Louisville KY Jefferson $ 21,772 31.80% 10.99% 40203 Louisville KY Jefferson $ 15,937 45.90% 17.55%

40216 Louisville KY Jefferson $ 36,354 10.70% 5.67% 40212 Louisville KY Jefferson $ 24,272 30.80% 12.22% 40165 Shepherdsville KY Bullitt $ 46,226 8.83% 8.31% 40229 Louisville KY Jefferson $ 49,233 8.50% 3.10% 40210 Louisville KY Jefferson $ 20,442 33.40% 12.59% 40272 Louisville KY Jefferson $ 42,391 8.40% 4.83% 40219 Louisville KY Jefferson $ 36,664 10.90% 5.95% 40214 Louisville KY Jefferson $ 36,446 11.90% 4.31% 40065 Shelbyville KY Shelby $ 47,628 10.22% 7.07% 40004 Bardstown KY Nelson $ 37,313 11.30% 8.31% 40258 Louisville KY Jefferson $ 45,513 7.40% 4.59% 40215 Louisville KY Jefferson $ 23,799 26.70% 9.29% 40218 Louisville KY Jefferson $ 32,218 14.50% 6.22% 40202 Louisville KY Jefferson $ 16,068 59.66% 20.13% 40206 Louisville KY Jefferson $ 41,536 11.90% 5.74%

40220 Louisville KY Jefferson $ 46,741 5.40% 2.91% 40299 Louisville KY Jefferson $ 63,437 4.10% 2.42% 40291 Louisville KY Jefferson $ 58,198 4.00% 2.79% 40205 Louisville KY Jefferson $ 62,103 4.50% 2.38% Kentucky $ 39,905 18.98% 8.40% United States $ 49,297 15.33% 7.90%

Median household income below 2012 Federal Poverty Level for a family of tw o adults and tw o children. Source: The Nielsen Company

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Exhibit 6 presents the average annual resident unemployment rates for counties in Jewish Hospital’s defined community illustrating that unemployment rates for all counties have risen in recent years. Most of the counties are similar to Kentucky’s state average which is slightly less favorable than national averages.

Exhibit 6 Unemployment Rate (%) Jewish Hospital CHNA Community Unemployment Rates (%) 2007-2011 County 2007 2008 2009 2010 2011

Jefferson, KY 5.5% 6.5% 10.1% 10.1% 10.0% Bullitt, KY 5.9% 7.1% 10.7% 10.8% 10.6% Nelson, KY 6.0% 7.5% 12.3% 11.7% 11.5% Shelby, KY 4.9% 5.9% 9.4% 9.1% 8.4%

Kentucky 5.6% 6.6% 10.3% 10.2% 9.5% United States 4.6% 5.8% 9.3% 9.9% 9.0%

Source : FDIC

Uninsured Status

Exhibit 7 presents health insurance coverage status by age (under 65 years) and income (at or below 400 percent of poverty) for each county compared to the state of Kentucky.

Exhibit 7 Jewish Hospital CHNA Community Health Insurance Coverage Status by Age (Under 65 years) and Income (At or Below 400%) of Poverty 2010 All Income Levels At or Below 400% of FPL Under 65 Percent Under 65 Percent Under 65 Percent Under 65 Percent County Uninsured Uninsured Insured Insured Uninsured Uninsured Insured Insured

Jefferson, KY 101,366 16.1% 529,450 83.9% 91,745 22.1% 323,697 77.9% Bullitt, KY 9,778 15.0% 55,494 85.0% 8,688 19.6% 35,554 80.4% Nelson, KY 6,316 16.6% 31,746 83.4% 5,748 20.6% 22,141 79.4% Shelby, KY 6,738 18.9% 28,938 81.1% 6,003 26.8% 16,376 73.2% Kentucky 640,974 17.5% 3,012,207 82.5% 585,339 22.4% 2,032,203 77.6%

Source: U.S. Census Bureau, SAHIE/ State and County by Demographic and Income Characteristics

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Education

The educational attainment of community residents may impact the local economy. Higher levels of education generally lead to higher wages, less unemployment and job stability. These factors may indirectly influence community health. Exhibit 8 indicates Jefferson County residents obtain a bachelor’s degree or higher at rates greater than state and national averages; in Bullitt County the rate is just 11.1 percent, about half the state average.

Exhibit 8 Jewish Hospital CHNA Community Educational Attainment by County - Ages 25 and Over High School Bachelor's Degree County/State Graduates or Higher

Jefferson, KY 86.90% 28.50% Bulllitt, KY 83.20% 11.10% Nelson, KY 83.80% 15.40% Shelby, KY 83.10% 23.20%

Kentucky 81.00% 20.30% United States 85.00% 27.90%

Source: U.S. Census Bureau, Current Population Survey

Community Health Care Resources

The availability of health care resources is critical to the health of a county’s residents and a measure of the soundness of the area’s health care delivery system. An adequate number of health care facilities and health care providers is vital to sustain a community’s health status. Fewer health care facilities and health care providers can impact the timely delivery of services. A limited supply of health resources, especially providers, results in the limited capacity of the health care delivery system to absorb charity and indigent care as there are fewer providers upon which to distribute the burden of indigent care. The next section addresses the availability of health care resources to the residents of Jewish Hospital’s service area.

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Hospitals

There are a large number of hospitals in Jewish Hospital’s service area with 4,295 licensed acute care beds, 666 psychiatric beds, 164 physical rehabilitation beds, 65 long-term care beds and eight neo-natal level II beds. Exhibit 9 summarizes hospital services available to the residents of Jewish Hospital’s service area.

Exhibit 9 Jewish Hospital CHNA Community Summary of Area Hospitals Long- Physical Neo-Natal Acute Psychiatric Term Rehabilitation Level II Facility County State Facility Type Beds Beds Beds Beds Beds

1 Baptist Hospital East Jefferson KY Short Term Acute Care 460 22 - 29 8 2 Flaget Memorial Hospital Nelson KY Short Term Acute Care 40 - 12 - - 3 Frazier Rehab Institute Jefferson KY Physical Rehabilitation - - - 135 - 4 Jewish Hospital Jefferson KY Short Term Acute Care 517 20 - - - 5 Jewish Hospital / Shelbyville Shelby KY Short Term Acute Care 70 - 6 - - 6 Jewish Hospital Medical Center South Shepherdsville Bullitt KY Short Term Acute Care 60 - - - - 7 Kindred Hospital- Louisville Jefferson KY Long-Term 337 - 47 - - 8 Norton Audubon Hospital Jefferson KY Short Term Acute Care 432 - - - - 9 Norton Brownsboro Hospital Jefferson KY Short Term Acute Care 127 - - - - 10 Norton Hosp/Kosair Children's Hosp/Alliant Medical Pavilion Jefferson KY Short Term Acute Care 859 46 - - - 11 Norton Suburban Hospital Jefferson KY Short Term Acute Care 373 - - - - 12 Our Lady of Peace Jefferson KY Psychiatric - 396 - - - 13 Saints Mary & Elizabeth Hospital Jefferson KY Short Term Acute Care 298 - - - - 14 The Brook Hospital - KMI Jefferson KY Psychiatric - 86 - - - 15 The Brook Hospital - Dupont Jefferson KY Psychiatric - 76 - - - 16 University of Louisville Hospital Jefferson KY Short Term Acute Care 384 20 - -

4,295 666 65 164 8 Source: http://chfs.ky.gov

1, 11, 15

3, 4, 7, 8, 1, 16

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Community Health Needs Assessment 2013

Ambulatory Care Clinics

The Kentucky Cabinet for Health and Family Services reports eight ambulatory care clinics within Jewish Hospital’s service area. The total number of ambulatory care clinics reported for the entire state of Kentucky is 20. The eight clinics reported for Jefferson County below represent 40% of Kentucky’s total ambulatory care clinics reported.

Exhibit 10 Jewish Hospital CHNA Community Summary of Ambulatory Care Clinics Facility Facility County Type

Baptist East Ambulatory Care Center - Bardstown Road Jefferson Ambulatory Care Clinic Baptist Eastpoint Ambulatory Care Center Jefferson Ambulatory Care Clinic Baptist Promptcare Jefferson Ambulatory Care Clinic Baptist Urgent Care Jeffersontown Jefferson Ambulatory Care Clinic Jewish Hospital Medical Center Northeast Jefferson Ambulatory Care Clinic Jewish Hospital Medical Center East Jefferson Ambulatory Care Clinic Jewish Hospital Medical Center Southwest Jefferson Ambulatory Care Clinic Kosair Children's Medical Center Pediatric Outpatient Center Jefferson Ambulatory Care Clinic

Source:http://chfs.ky.gov

Other Licensed Facilities

There are licensed facilities other than hospitals and ambulatory care clinics in Jefferson County. These facilities include home health, hospice, adult day care, ambulatory surgery centers, rehabilitation agencies and private duty nursing providers. A complete inventory may be obtained through the Kentucky Cabinet for Health and Family Services at http://chfs.ky.gov/ohp/con/inventory.htm.

Physicians

Jewish Hospital conducted an analysis that compared physician supply and estimated physician demand utilizing Truven Health Analytics. It indicated shortages in general/family medicine and cardiology.

Health Departments

There are several county health departments located within Jewish Hospital’s CHNA community: Louisville Metro Public Health & Wellness (LMDPHW); Bullitt County Health Department; Lincoln Trail District Health Department which serves Nelson County and North Central Health Department which serves Shelby County. As stated earlier, Jewish Hospital collaborated with the LMDPHW to conduct its community health needs assessment as the majority of patients originate in Jefferson County.

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Community Health Needs Assessment 2013

LMDPHW has 350 highly-trained employees providing a wide range of services to the people of Louisville, including:

Health clinics Information about Louisville’s smoke free law Inspection of eating establishments Helping the children of Louisville Metro grow up healthy

LMDPHW operates multiple preventive health clinics and educational programs throughout Louisville Metro to community members regardless of their residency status or ability to pay. Clinics operated under the direction of LMDPHW and privately operated Federally Qualified Healthcare Centers are reported in Appendix D, Page 42.

Services provided by LMDPHW include: dental care, WIC, immunizations, family planning, pregnancy tests, head lice checks, cancer screens, sexually transmitted infection testing, tuberculosis testing, diagnosis and treatment and well child exams.

Although LMPHW does not provide direct prenatal or primary care services, the department partners with community experts in the field to assure access to these services for the whole community. Primary partner agencies include Family Health Centers, Inc., The University of Louisville and Park DuValle Commu- nity Health Center.

The department also operates some mobile preventive clinics that can be deployed for mass vaccination, infectious disease outbreaks or service delivery to underserved areas.

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Community Health Needs Assessment 2013

Health Status of the Community

This section of the assessment reviews the health status of Jefferson County residents. As in the previous section, comparisons are provided with the state of Kentucky and the United States. This in-depth assessment of the mortality and morbidity data, health outcomes, health factors and mental health indicators of Jefferson County residents that make up the community will enable Jewish Hospital to identify priority health issues related to the health status of its residents.

Good health can be defined as a state of physical, mental, and social well-being, rather than the absence of disease or infirmity. According to Healthy People 2010, the national health objectives released by the U.S. Department of Health and Human Services, individual health is closely linked to community health. Community health, which includes both the physical and social environment in which individuals live, work and play, is profoundly affected by the collective behaviors, attitudes and beliefs of everyone who lives in the community. Healthy people are among a community’s most essential resources.

Numerous factors have a significant impact on an individual’s health status: lifestyle and behavior, human biology, environmental and socioeconomic conditions, as well as access to adequate and appropriate health care and medical services. Studies by the American Society of Internal Medicine conclude that up to 70 percent of an individual’s health status is directly attributable to personal lifestyle decisions and attitudes. People who do not smoke, who drink in moderation (if at all), use automobile seat belts (car seats for infants and small children), maintain a nutritious low-fat, high-fiber diet, reduce excess stress in daily living and exercise regularly have a significantly greater potential of avoiding debilitating diseases, infirmities and premature death.

The interrelationship among lifestyle/behavior, personal health attitude and poor health status is gaining recognition and acceptance by both the general public and health care providers. Some examples of lifestyle/behavior and related health care problems include the following:

Lifestyle/Behavior Primary Disease Factor

Smoking Lung cancer Emphysema Cardiovascular disease Chronic bronchitis

Alcohol/Drug Abuse Cirrhosis of liver Malnutrition Motor vehicle crashes Mental illness Unintentional injuries Suicide

Poor Nutrition Obesity Digestive disease Depression

Driving at Excessive Speeds Trauma Motor vehicle crashes

Lack of Exercise Cardiovascular disease Depression

Overstressed Mental illness Alcohol/Drug abuse Cardiovascular disease

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Community Health Needs Assessment 2013

Health problems should be examined in terms of morbidity as well as mortality. Morbidity is defined as the incidence of illness or injury and mortality is defined as the incidence of death. However, the law does not require reporting the incidence of a particular disease, except when the public health is potentially endangered.

Due to limited morbidity data, this health assessment relies heavily on death and death rate statistics for leading causes of death. Such information provides useful indicators of health status trends and permits an assessment of the impact of changes in health services on a resident population during an established period of time. Community attention and health care resources may then be directed to those areas of greatest impact and concern.

Leading Causes of Death

According to the 2012 Louisville Metro Health Status Report, malignant neoplasm, commonly known as cancer, was the number one cause of death in Louisville Metro during 2009 (the latest year for which mortality data is available), accounting for 23 percent of all deaths. In addition to cancer, the other top causes of death are heart disease, chronic lower respiratory disease (including COPD), stroke/cerebrovascular disease and unintentional injuries. See Appendix B, Page 43.

Percentage of Total Deaths Due to Leading Causes of Death Louisville Metro, 2009 Malignant Neoplasms (All cancers combined) Diseases of Heart

Chronic Lower Respiratory Disease Stroke/Cerebrovascular 23% 25% Disease Unintentional Injury

Alzheimer's Disease

2% Diabetes 3% Septicemia 3% 21% Nephritis, Nephrotic 3% Syndrome & Nephrosis Influenza & Pneumonia 3% 5% 6% 6% All other Causes

Source: 2012 Louisville Metro Health Status Report, LMDPHW

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Exhibit 11 reflects leading causes of death for each county and compares the rates, per thousand, to the state and U.S. rates, per thousand. Jefferson County death rates are slightly higher than state averages.

Exhibit 11 Jewish Hospital CHNA Community Leading Causes of Resident Deaths: By County

Bullitt Jeferson Nelson Shelby KY US Rate* Rate Rate* Rate* Rate* Rate* Cause of Death - All Ages (Rate) All causes 586.5 969.9 701.3 688.2 946.0 798.8 Diseases of Heart 138.6 241.6 177.8 185.8 253.4 211.1 Malignant Neoplasms 134.4 237.3 202.1 162.2 223.9 183.8 Chronic Lower Respiratory Disease 50.4 65.4 43.8 20.9 61.0 43.2 Cerebrovascular Diseases 26.6 53.6 53.6 65.4 50.7 46.6 Unintentional Injuries 37.8 41.5 63.3 31.4 54.3 39.1 Alzheimer's Disease 15.4 26.3 7.3 23.6 27.1 22.9 Diabetes Mellitus 18.2 36.3 - 13.1 28.0 24.6 Intentional Self Harm (Suicide) 15.4 - 17.0 - - 10.9 Influenza and Pneumonia 12.6 19.9 19.5 15.7 23.9 20.3 Pneumonitis due to Solids and Liquids 9.8 - - - - Nephritis, Nephrotic Syndrome and Nephrosis - 22.2 14.6 15.7 21.3 14.3 Septicemia - 18.0 - 13.1 13.8 11.2

*Age-adjusted rates are per 100,000 population.

Primary Health Conditions Responsible for Inpatient Hospitalization

The 2012 Louisville Metro Health Status Report noted the top four health conditions responsible for inpatient hospitalizations are heart disease, mental or emotional diagnosis, chronic obstructive pulmonary disease (COPD) and cancer.

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Health Outcomes and Factors

Health Statistics and Rankings

An analysis of various health outcomes and factors for a particular community can, if improved, help make that community a healthier place to live, learn, work, and play. And a better understanding of the factors that affect the health of the community will assist with how to improve the community’s habits, culture and environment. This portion of the community health needs assessment utilizes information from County Health Rankings, a key component of the Mobilizing Action Toward Community Health (MATCH) project, a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute.

The County Health Rankings model is grounded in the belief that programs and policies implemented at the local, state and federal levels have an impact on the variety of factors that, in turn, determine the health outcomes for communities across the nation. The model ranks all 50 states and the counties within each state based on two types of health outcomes—how long people live (mortality) and how healthy people feel (morbidity)—and four health factors. These are defined below:

Health Outcomes – rankings are based on an equal weighting of one length of life (mortality) measure and four quality of life (morbidity) measures.

Health Factors – rankings are based on weighted scores of four factors:

o Health behaviors (6 measures) o Clinical care (5 measures) o Social and economic (7 measures) o Physical environment (4 measures)

Those having high ranks, e.g. 1 or 2, are considered to be the ―healthiest.‖ A more detailed discussion about the ranking system, data sources and measures, data quality and calculating scores and ranks can be found at the website for County Health Rankings (www.countyhealthrankings.org).

As part of this community health needs assessment, the relative health status of Jefferson County is compared to the state of Kentucky and a national benchmark. A better understanding of the factors that affect the health of the community will assist with how to improve the community’s habits, culture and environment.

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The following table from County Health Rankings summarizes the 2012 health outcomes for all counties that comprise the majority of the community for Jewish Hospital. Each measure is described and includes a confidence interval or error margin surrounding it–– if a measure is above the state average and the state average is beyond the error margin for the county, then further investigation is recommended.

Health Outcomes—rankings are based on an equal weighting of one length of life (mortality) measure and four quality of life (morbidity) measures. While most of the counties within Jewish Hospital’s service area compare favorably to state of Kentucky, each measure was significantly below national benchmarks with opportunities for improvement.

Exhibit 12 Jewish Hospital CHNA Community Health Outcomes (2012) Bullitt Jefferson Nelson Shelby National County County County County KY Benchmark*

Mortality Premature death - Years of potential life lost before age 75 per 100,000 population (age-adjusted) 6,382 8,405 8,032 6,628 8,761 5,466

Morbidity Poor or fair health - Percent of adults reporting fair or poor heatlh (age-adjusted) 20% 17% 19% 17% 22% 10% Poor physical health days - Average number of physically unhealthy days reported in past 30 days (age- adjusted) 5.5 4.0 4.0 4.5 4.7 2.6 Poor mental health days - Average number of mentally unhealthy days reported in past 30 days (age-adjusted) 4.9 3.8 3.6 3.2 4.3 2.3 Low birthweight - Percent of live births with low birthweight (<2500 grams) 8.4% 9.4% 8.7% 8.6% 9.0% 6%

* 90th percentile, i.e., only 10% are better

Source: Countyhealthrankings.org

A number of different health factors shape a community’s health outcomes. The County Health Rankings model includes four types of health factors: health behaviors, clinical care, social and economic and the physical environment.

Exhibit 13 summarizes the health factors for the four counties included in Jewish Hospital’s primary service area. The community has a very good supply of physicians. However, the community is challenged by high rates of adult smoking, obesity, and sexually transmitted infections. The violent crime rate in Jef- ferson County is significantly higher than state and national benchmarks.

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Exhibit 13 Jewish Hospital CHNA Community Health Factors (2012) Bullitt Jefferson Nelson Shelby National County County County County KY Benchmark*

Health Behaviors Adult smoking - Percent of adults that report smoking at least 100 cigarettes and that they currently smoke 31.0% 24.0% 29.0% 25.0% 27.0% 14.0% Adult obesity - Percent of adults that report a BMI >= 30 34.0% 34.0% 30.0% 35.0% 33.0% 25.0% Physical inactivity - Percent of adults aged 20 and over reporting no leisure time physical activity 34.0% 29.0% 29.0% 28.0% 31.0% 21.0% Excessive drinking - Percent of adults that report excessive drinking in the past 30 days 8.0% 14.0% 19.0% 11.0% 10.7% 8.0% Motor vehicle crash death rate - Motor vehicle deaths per 100K population 17.0 13.0 24.0 20.0 22 12 Sexually transmitted infections - Chlamydia rate per 100K population 173.0 568.0 436.0 321.0 311 84 Teen birth rate - Per 1,000 female population, ages 15-19 35.0 51.0 50.0 49.0 52 22

Clinical Care Uninsured - Percent of population under age 65 without health insurance 15.0% 14.0 15.0% 17.0% 17.0% 11.0% Primary care physicians - Ratio of population to primary care physicians 5,749:1 740:1 2395:1 2069:1 1232:1 631:1 Preventable hospital stays - Hospitalization rate for ambulatory-care sensitive conditions per 1,000 Medicare enrollees 82.0 68-72 62.0 79.0 104 49 Diabetic screening - Percent of diabetic Medicare enrollees that receive HbA1c screening 82.0% 85.0% 82.0% 82.0% 82.0% 89.0% Mammography screening - Percent of female Medicare enrollees that receive mammorgraphy screening 68.0% 70.0% 62.0% 71.0% 63.0% 74.0%

Social & Economic Factors High school graduation - Percent of ninth grade cohort that graduates in 4 years 81.0% 71.0% 100.0% 76.0% 78.0% X Some college - Percent of adults aged 25-44 years with some post- secondary education 53.0% 66.0% 49.0% 56.0% 55.0% 68.0% Unemployment - Percent of population age 16+ unemployed but seeking work 10.8% 10.6% 11.7% 9.1% 10.5% 5.4% Children in poverty - Percent of children under age 18 in poverty 15.0% 24% 22.0% 18.0% 26.0% 13.0% Inadequate social support - Percent of adults without social/emotional support 21.0% 19.0% 18.0% 13.0% 20.0% 14.0% Children in single-parent households - Percent of children that live in household headed by single parent 30.0% 41.0% 29.0% 27.0% 32.0% 20.0% Violent crime rate - Deaths due to homocide per 100,000 population (age-adjusted) 130.0 646.0 145.0 191.0 288 73

Physical Environment Air pollution-particulate matter days - Annual number of unhealthy air quality days due to fine particulate matter 1 8 - - 2 - Air pollution-ozone days - Annual number of unhealthy air quality days due to ozone 1 7 - - 2 - Limited access to healthy foods - Percent of population who are low- income and do not live close to a grocery store 17.0% 5.0% 20.0% 15.0% 7.0% - Access to recreational facilities - Rate of recreational facilities per 100,000 population 9.0 10.0 14.0 5.0 8 16 Fast food restaurants - Percent of all restaurants that are fast-food establishments 70.0% 55.0% 53.0% 63.0% 54.0% 25.0%

* 90th percentile, i.e., only 10% are better Note: X indicates unreliable or missing data

Source: Countyhealthrankings.org

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Primary Data

Community Input-Surveys

As previously stated, to obtain feedback from the general public, surveys were conducted by the LMDPHW in collaboration with a consortium of area hospitals. This included an assessment of community perceptions of major barriers to health care. The overwhelming majority of respondents strongly agreed or agreed that cost/expense (89 percent) and insurance issues (86 percent) are big barriers to health care. Other big barriers include health knowledge, health beliefs and knowing where to go in a health facility. Ninety-five percent of respondents felt they had access to preventive care and 72 percent believe that health providers give them needed education and resources.

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Community Health Needs Assessment 2013

The survey solicited input from participants regarding health problems of the community. Addiction, chronic diseases, including diabetes/high blood pressure, heart disease and stroke, and emerging issues, primarily obesity, were identified as the biggest health problems in the community.

Big Health Problems

0.5

0.4

0.3

0.2

0.1

0 Addiction Mental Respiratory Cancer Other Emerging Illness Illness Chronic Issues Diseases

Louisville Metro Health Department, 2012 Community Health Needs Assessment Survey Results General Public Survey

The majority (74 percent) said there were people in their community who need care but cannot get it; yet 84 percent said they had seen a primary care provider in the last 12 months and 95 percent said they had access to preventive services. Forty percent of respondents identified low income families and elderly as the groups in need of the most help with access to health care. Furthermore, to improve children’s health in Louisville Metro, respondents recommended the following:

Increase insurance coverage Provide health facilities on school campuses Create more opportunities for exercise and availability of fruits and vegetables

Children and teens Respondents’ Opinion on a 125, 7% Group Needing the Most Young adults Help with Access to Health 176, 10% Care 58, 3% Immigrant and refugees 738, 41% 124, 7% Minority groups (i.e. African-American, Hispanic) Elderly

Lesbian, Gay, Bisexual and 473, 26% Transgender (LGBT) Physical or Mentally disabled 88, 5% Low income families 14, 1%

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Community Health Needs Assessment 2013

The majority of respondents considered lowering the cost of health care and prescription drugs and increasing access to primary care doctors as the best ways to address health needs of people in their community. Furthermore, respondents recommended that wellness goals could be met through increased funding or free services and providing more education and prevention programs.

Availability of health screenings (i.e., cancer screening) More places to exercise 148, 8% 205, 11% Best Ways to Address the Access to fresh fruit and Health Needs of People in vegetables 101, 5% Quit smoking classes Their Community 68, 4% 31, 2% 10, 0% Diabetes management classes

More access to primary care 215, 12% doctor/physicians

884, 49% More access to specialists

Nutrition education 120, 7% 35, 2% Lower cost of health care and prescription drugs No opinion/I don't know

The perceptions of the physician/community leader survey participants reflected slightly different priorities. Ninety-five percent said they thought there were medically underserved areas of the community. Se- venty-nine percent said that various organizations in the community they served were not meeting health and wellness needs. Only 14 percent felt Louisville was doing a good or very good job on preventive care, while 53 percent thought the city was doing a poor or very poor job. The verdict was not any better when it came to providing mental health services; 54 percent said Louisville was a doing a poor or very poor job.

Sixty-nine percent of the physician/community leader respondents said that Louisville was doing a good or very good job providing immunizations, while 16 percent said the city was doing a good job providing oral health services. Only 25 percent said the city was doing a good or very good job of drug and alcohol treatment, while 34 percent thought was doing a poor or very poor job.

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The physician/community leader group also identified different priority health issues. Sixty-four percent identified obesity as the most prevalent emerging health issue.

0% 0% Most Prevalent Emerging Health 10% Issues in the Obesity Community HIV/AIDS 21% All of the above

Other None 5% 64% No opinion/I don't know

This group felt the best way to address the needs of medically underserved areas was to increase access to primary care physicians (40 percent), lower the cost of health care and prescription drugs (15 percent) and improve availability to health screenings (15 percent). When asked how leaders and health care organizations could collaborate to meet the health care needs of the communities they serve, most pointed to easier access to services (25 percent), advocating for better health policy (18 percent), increased support for free or income-based services (17 percent) and more education and prevention programs (17 percent).

Key Themes Provided Through Participant Comments

―We can screen—provide information—but if people are uninsured they need ACCESS for not just emergency care…most clinics are so busy and burdened they are not always able to spend time on education.‖

―The young children and adults need to be taught in school about health care because they are learning from their parents and the parents have no idea how to handle the health care problems…‖

―There is no place, building, office, etc. in my community the people can go for information, advocacy, advice, etc.‖

―My clients struggle to navigate an extremely poorly devised system that presents limited resources.‖

―Provide clear/precise information for expected cost/coverage of health care not covered by insurance benefits – current policy very confusing‖

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Community Health Needs Assessment 2013

Health Issues of Uninsured Persons, Low-Income Persons and Minority Groups

To assess health issues impacting those in people the community who are low-income, uninsured or from minority groups, Jewish Hospital reviewed the Louisville Metro Health Equity Report issued in 2011 by the LMDPHW and its Center for Health Equity (See Appendix D). According to the report:

Louisvillians in the poorest neighborhoods have lower life expectancies, sometimes by as much as 10 years shorter than the overall Louisville Metro life expectancy. Louisville residents ages 40-65 who earn less than $20,000 annually are significantly more likely to report that they have had a heart attack. Opportunities for physical activity in some neighborhoods could be impeded by safety issues including hazards for pedestrians and bicyclists, or high rates of violent crime in or near public parks.

The following charts are excerpted from the LMDPHW 2011 Health Equity Report:

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Violence in the Community With a violent crime rate of 646 per one 100,000 residents, Jefferson County has one of the highest crime rates in America compared to all communities of all sizes—from the smallest towns to the very largest cities.

Exhibit 14 Jewish Hospital CHNA Community Louisville Metro Crime Statistics Summary Report 2010 Crime (Actual Data)* Incidents

Aggravated Assault 1,850 Arson 223 Burglary 7,571 Forcible Rape 229 Larceny and Theft 20,005 Motor Vehicle Theft 1,975 Murder and Manslaughter 52 Robbery 1,603 Crime Rate (Total Incidents) 32,804 Property Crime 29,551 Violent Crime 3,734

Source: FBI Report of Offenses Known to Law Enforcement

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Community Health Needs Assessment 2013

Priority Community Health Needs Identified

Using findings obtained through the community survey and collection of primary and secondary data enabled Jewish Hospital completed an analysis of these inputs (see Appendix E) to identify community health needs. The following data was analyzed to identify health needs for the community:

Leading Causes of Death: Leading causes of death for the community were reviewed and the death rates for the leading causes of death for each county within the Jewish Hospital CHNA community were compared to U.S. adjusted death rates. Causes of death in which the county rate compared unfavorably to the U.S. Adjusted death rate resulted in a health need for the Jewish Hospital CHNA community. Primary Causes for Inpatient Hospitalization: The primary causes for inpatient hospitalization resulted in an identified health need for the community. Health Outcomes and Factors: An analysis of the County Health Rankings health outcomes and factors data was prepared for each county within the Jewish Hospital CHNA community. County rates and measurements for health behaviors, clinical care, social and economic factors and the physical environment were compared to national benchmarks. County rankings in which the county rate compared unfavorably (by greater than 30 percent of the national benchmark) resulted in an identified health need. Primary Data: Health needs identified through community surveys, focus groups and key informant interviews (if applicable) were included as health needs. Needs for vulnerable populations were separately reported on the analysis in order to facilitate the prioritization process.

To facilitate prioritization of identified health needs, a ranking and prioritization process was used. Health needs were ranked based on the following seven factors. Each factor received a score between 0 and 4.

1) How many people are affected by the issue or size of the issue? For this factor ratings were based on the percentage of the community who are impacted by the identified need. The following scale was utilized for health outcomes and factors: >20% of the community population=4; >10% and <20%=3; >5% and <10%=2 and <5%=1. Chronic diseases were rated based on state ranking for incidence of the disease. A factor of 1-4 was assigned based on which quartile the state was reported. 2) What are the consequences of not addressing this problem? Identified health needs which have a high death rate or have a high impact on chronic diseases received a higher rating for this factor. 3) The impact of the problem on vulnerable populations. Needs associated with vulnerable populations identified through the community health needs assessment process were rated for this factor. 4) How important the problem is to the community. Needs identified through community surveys and/or focus groups. 5) Prevalence of common themes. Determined by how many sources of data (Leading Causes of Death, Primary Causes for Inpatient Hospitalization, Health Outcomes and Factors and Primary Data) identified the need. 6) How closely does the need align with KentuckyOne Health strategies? 7) Does the hospital have existing programs which respond to the identified need?

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Community Health Needs Assessment 2013

As a result, the following summary list of needs was identified:

Stroke/cerebrovascular disease Chronic diseases in vulnerable neighborhoods (defined by health outcomes, race and socieo- economic status) Chronic lower respiratory disease Cancer Adult obesity Heart disease Physical inactivity Access to care Brain disorders (mental/emotional health) Shortage of primary care physicians Violent crime Limited access to healthy foods Addiction/substance abuse Adult smoking Limited health knowledge and health education

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Each need was then ranked based on these seven prioritization metrics. These were the top priority issues that emerged:

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APPENDICES

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Appendix A: 2012 Louisville Metro Health Status Report

2012

Louisville Metro Health Status Report

Louisville Metro Health Status Report 2012

Louisville Metro Department of Public Health and Wellness (LMPHW) Director: LaQuandra Nesbitt, MD, MPH

Produced by: Office of Policy Planning and Evaluation, LMPHW Director: Makeda S. Harris, MPM Epidemiologists: Carl Hall, PhD and Haritha Pallam, MS, MPH

Other Contributors: Yu-Ting Chen, MPH

Acknowledgements: Division of Environmental Health and Preparedness, LMPHW Division of Community Health and Prevention, LMPHW Kentucky Department for Public Health, Cabinet for Health and Family Services Kentucky Department of Education Kentucky Police Department

LOUISVILLE, KENTUCKY

LOUISVILLE METRO PUBLIC HEALTH & WELLNESS

GREG FISHER LAQUANDRA NESBITT, MD, MPH Mayor Director

To the Readers of this Report:

The field of public health is ever changing. We now know more about the root causes of illness, disease and disability than we did twenty years ago. In fact, we now understand that the social determinants of health such as education, income, race/ethnicity, and health behaviors like smoking, lack of physical activity, and poor nutrition; have a greater impact on our health than the care we receive in a hospital or a doctor’s office. This knowledge helps the Louisville Metro Department of Public Health and Wellness (LMPHW) develop and implement policies, programs, and practices that lead to safer and healthier communities where we live, learn, work, play, and worship.

The 2012 Louisville Metro Health Status Report is designed to build community capacity to identify and address risks to health and well-being. It is a way for LMPHW to share information about the overall health and well-being of Louisville Metro with residents, healthcare providers, community leaders, and other key stakeholders. The report highlights the major health conditions that Louisville Metro residents face as well as key health behaviors that can be modified to increase our ability to become a healthier community. The report also identifies some of the significant health disparities that impact quality of life and prevent our most vulnerable residents from living healthy and productive lives.

It is our hope that this report will serve as a call to action for all readers to join with LMPHW in addressing our key health issues and make strides toward our goal of becoming the healthiest city in America!

For additional information or to share ideas on how this bi-annual report can be improved, please contact our Office of Policy Planning and Evaluation at 502-574-8270.

LaQuandra S. Nesbitt, MD, MPH Director

LOUISVILLE METRO HEALTH STATUS REPORT 2012

TABLE OF CONTENTS

EXECUTIVE SUMMARY 5

METHODOLOGY 10

HEALTHY PEOPLE 2010 12

DEMOGRAPHIC AND SOCIO-ECONOMIC PROFILE 13

MATERNAL AND CHILD HEALTH 24

HOSPITAL DATA 38

CAUSES OF DEATH 41

CHRONIC DISEASES 45

BEHAVIORAL RISK FACTORS 61

MENTAL HEALTH 64

INJURY AND VIOLENCE 66

COMMUNICABLE DISEASES 78

GLOSSARY OF TERMS 95

ENDNOTES 96

APPENDIX 100

EXECUTIVE SUMMARY

One of the core functions of a public health department is to assess the health needs of the community. This report is part of our assessment of the Louisville Metro community and includes indicators in the following areas:

Demographic and Socio-Economic Profile Maternal and Child Health Hospital Data Causes of Death Chronic Diseases Behavioral Risk Factors Mental Health Injury and violence Communicable Diseases

Demographic and Socio-Economic Profile

As of 2010, Louisville Metro had a total population of 741,096. Over the past decade, the white population remained stagnant while other racial and ethnic groups steadily increased. Following the national trends, growth among the Hispanic population increased by 163.1%. Among the total population of Louisville metro, the black population increased from 17.3% in 2000 to 21% in 2010. In Louisville Metro population between year 2000 and 2010 there was a 15% decrease in the 35 to 44 year old age group and over 50% increase in the 55 to 64 year old age group. According to U.S. Census estimates, the median household income in Louisville Metro was $44,437. This was lower than the national median income for the same year ($50,303). Approximately 8.3% of Louisville Metro residents 25 years and older did not earn a high school diploma in 2009. The annual unemployment rate in Louisville Metro was 10.6% by the end of 2010. In 2009, 89% of Louisville Metro residents reported having some type of health care coverage. This was higher than the nation (85%) and the state of Kentucky (86%).

Maternal and Child Health

The number of live births in Louisville Metro was 9,815 in 2009. This is a 7.5% decrease from the previous year. The infant mortality rate for Louisville Metro in 2009 (6.7 deaths per 1,000 live births) was higher than the Healthy People 2010 goal and the reported rates for Kentucky. In 2009, 9.1% of the births were classified as low birth weight and of these, 21% were very low birth weight. Blacks (38%) had the highest number of mothers that did not receive prenatal care in the first trimester, followed by Hispanics (31.4%).

Black females 15 to 19 years of age had a teen birth rate approximately three times higher than that of white females (90.7 per 1,000 births compared to 33.6). Almost 24% of women who gave birth to a low birth weight infant reported smoking during pregnancy.

Childhood Lead Exposure

Over 20,000 Louisville Metro children were screened for elevated blood lead levels by the Childhood Lead Poisoning Prevention Program (CLPPP) in 2009 and 2010. The percentage of children exhibiting elevated blood lead levels equal or greater than 10µg/dL steadily declined between 2000 and 2010. While mean blood lead levels have steadily declined for both black and white children over the past several years, the levels for black children remained higher.

Hospital Data

In 2009, the top five primary health conditions responsible for inpatient hospitalizations in Louisville Metro were heart diseases, mental or emotional diagnosis, COPD, cancer and stroke. For youth below the age of 20 years old, mental or emotional diagnosis, unintentional injuries, COPD and asthma were the leading primary health conditions for inpatient hospitalizations.

Causes of Death

The age-adjusted death rate from all causes in Louisville Metro was 1,137 per 100,000 population in 2009. For Louisville Metro blacks, the age-adjusted death rate from all causes was 17% higher when compared to Louisville Metro whites. The age-adjusted death rate for males was 36.5% higher than the rate for females. The top five leading causes of death for Louisville Metro as of 2009 remained the same as the previous year: 1. Cancer (or Malignant Neoplasms) 2. Heart Disease 3. Chronic Lower Respiratory Disease 4. Stroke (or Cerebrovascular Disease) 5. Unintentional Injuries Louisville Metro black residents had a higher death rate from heart disease and cancer while white residents had a higher death rate from chronic lower respiratory diseases (including COPD) and unintentional injuries.

Chronic Diseases

Heart Disease The age-adjusted rate of death for heart disease in Louisville Metro during 2009 was 237.4 per 100,000 population. The age-adjusted death rate of Louisville Metro blacks for heart disease was 36% higher than the rate for whites.

Cancers (Malignant Neoplasms) The age-adjusted cancer death rate in Louisville Metro was 256.2 deaths per 100,000 population in 2009. The cancer death rate for blacks (327 per 100,000 population) was 31% higher than the rate for whites (250 per 100,000 population).

Chronic Obstructive Pulmonary Disease (COPD) The age-adjusted death rate for COPD in Louisville Metro during 2009 was 63 per 100,000 population. The age-adjusted death rate from COPD for whites was 79% higher than the death rate for blacks (68 compared to 38 per 100,000).

Stroke or Cerebrovascular Disease The age-adjusted death rate for strokes in Louisville Metro during 2009 was 67 per 100,000 population. The age-adjusted death rate from stroke for blacks was higher than the death rate for whites (73 compared to 67 per 100,000).

Diabetes The age-adjusted diabetes death rate was 35 per 100,000 population for Louisville Metro in 2009. For Louisville Metro blacks, the age-adjusted death rate from diabetes was more than double the rate for whites (76 compared to 28 per 100,000).

Asthma In 2009, 15% of adults surveyed in Louisville Metro reported they had asthma. This percentage was slightly higher than the state (14.9%) and national percentage (13.5%).

Behavioral Risk Factors

According to the 2009 Behavioral Risk Factor Surveillance System (BRFSS) survey conducted by Kentucky Cabinet for Health and Family Services, the percentage of Louisville Metro adults either obese or overweight based on reported height and weight has continued to increase from previous years. As of 2009, approximately 65% were either obese or overweight. Seventy-four percent of Louisville Metro adults reported participating in any physical activities other than their regular job during the past month. Examples of physical activities include running, calisthenics, golf, gardening, or walking for exercise. This is higher than the percentage for Kentucky (69.5%) In 2009, Louisville Metro adults reported eating five or more servings of fruits and vegetables each day (24%) which was higher than Kentucky (21.1%) and the United States (23.4%). The percentage of Louisville Metro adults that reported they smoke tobacco decreased from 25.5 in 2004 to 23.9% in 2009.

Mental Health

Fifteen percent of BRFSS respondents reported fourteen (14) or more days during the past month that were considered as “mentally unhealthy”. In 2009, higher percentage of females (9.4%) reported having “mentally unhealthy” days compared to men (5.2%).

Injury and Violence

Unintentional Injury In 2009, the age-adjusted death rate from unintentional injury was 56 per 100,000 population. The death rate from unintentional injury for males was twice the rate for females (80 compared to 37). The largest category of unintentional injury deaths was motor vehicle crashes (32%), followed by accidental poisonings (29.8%) and falls (21.6%). The Louisville Metro death rate from traffic-related motor vehicle crashes was 16 deaths per 100,000 population.

Bicycle and Pedestrian Collisions Between 2001 and 2010, the number of pedestrian collisions in Louisville Metro ranged from 382 to 431 and the number of pedestrian fatalities ranged from 10 to 19. During the same period, the number of bicycle collisions varied from 163 to 166 and the number of fatalities ranged from 1 to 3. One hundred percent of bicycle and 68.4% pedestrian collisions occurred during non-rush hours in 2010.

Homicide In 2009, the homicide death rate in Louisville Metro was 11 deaths per 100,000 population. The homicide death rate for blacks was approximately seven times that of whites. The death rate for males was four times that for females.

Suicide In 2009, the Louisville Metro death rate from suicide was 14 deaths per 100,000 population. Males in Louisville Metro had a suicide rate nearly three times greater than females (22 compared to 8). The suicide rate among Louisville Metro whites (16) was more than double that of blacks (7) and higher than the state and national rates.

Communicable Diseases

There is no clear trend in the incidence of newly diagnosed HIV cases reported to the state from 2005 through 2009. Among those individuals with newly diagnosed HIV for whom a mode of exposure has been determined and reported, the predominant mode of exposure was men who have sex with men (37.4%) followed by injection drug use (6.1%). Blacks had an HIV incidence rate almost 4 times higher than that seen in Whites. Although the incidence of primary and secondary syphilis cases in Louisville Metro has varied over the past five years, the rate increased 50% from 3.8 to 5.7 per 100,000 population in 2009 compared to 2008. Males have much higher rates than females. Black rates for gonorrhea, Chlamydia, tuberculosis, and Pertussis are higher than the rates for Whites.

METHODOLOGY

Terminology For purposes of this report, specific terms of reference were selected. For race and ethnic categories, the terms “white,” “black,” and “Hispanic” are used. White and black refer to race categories. Other race categories, such as Asian/Pacific Islander and American Indian, are included in the analysis if appropriate. However, Hispanic refers to an ethnic category and not one race. If the analysis combines race and ethnicity, the designations become, for example, “White Hispanic” or “Non-White, Hispanic.”

In 2003, the city of old Louisville merged with surrounding municipalities in Jefferson County to form a consolidated city-county government named Louisville Metro-Jefferson County Metro Government, commonly referred to as Louisville Metro. This report uses the term “Louisville Metro” to represent the entire Jefferson County region. This includes existing independent municipalities within the Louisville Metro area.

Data Analysis Data sources utilized in this report includes data from vital statistics obtained from Kentucky Department for Public Health, U.S. Census, U.S. Centers for Disease Control and Prevention (CDC), as well as data collected and maintained at Louisville Metro Department of Public Health and Wellness (LMPHW). Comparisons to state and national data, Healthy People 2010, trends over time, and geographic distributions are included on selected indicators.

The report uses the most current data available at the time of publication. The 2009 data is the latest final birth and death statistics released by the Kentucky Cabinet for Health and Family Services Department for Public Health at the time this report was compiled. Data was also used from other sources when available.

Most sections provide bar charts showing the Louisville Metro rate compared to the state and national rates, in addition to Healthy People 2010 objectives from U.S. Department of Health and Human Services where one exists.

The rates for communicable disease incidence and for chronic disease-related hospitalizations are generally presented as a crude (unadjusted) rate per 100,000 population. For example, to compute a crude rate per 100,000 population for the year 2004 for gonorrhea, the steps are: Divide the number of new cases of gonorrhea reported during the year 2004 by the population of the area Multiply that result by 100,000

The above methodology also applies for inpatient hospitalizations rates. Rates were calculated using 2009 census population estimates.

The death (mortality) rates are computed as age-adjusted rates. The age-adjusted process compensates for the differences in the age composition of the population. First, a crude rate is calculated for each age category. Then the age-specific rate is multiplied by the proportion of the standard population that particular age category represents. These weighted age-specific rates are added together to make an age-adjusted rate for that population.

In addition to crude rates, age-specific rates and rates based on the number of live births are used in maternal and child health analysis.

Mortality trends presented in this report reflect reported cause of death based on the ICD-10 classification. Due to a change in coding cause of death in 1998, trends for pre-1999 data are not directly comparable to those for 1999 and later data.

Behavioral Risk Factor Surveillance System (BRFSS) This year’s report includes the Behavioral Risk Factor Surveillance System (BRFSS) phone survey conducted by the Kentucky Department for Public Health to gather information about these risk factors for Louisville Metro residents. The standardized questions were approved by the U.S. Centers for Disease Control and Prevention (CDC) and are used throughout the United States. Louisville Metro residents were selected for interviews by random dialing of phone numbers and remain anonymous.

Hospital Data This report presents administrative claims data for inpatient hospital discharges from Louisville Metro hospitals with dates of service between January 1, 2009 and December 31, 2009. These data sets are maintained by the Kentucky Cabinet of Health and Family Services and have been analyzed by the Louisville Metro Department of Public Health and Wellness. Estimates of diagnoses and primary conditions are presented according to the International Classification of Diseases (ICD), ninth revision, Clinical Modification Codes (see Appendix).

Inpatient data represents a collection on records each of which describes a single inpatient stay in a Louisville Metro hospital. Therefore, because persons can have multiple discharges within the same year, they can be sampled more than once. As a result, the data cannot be used to directly measure the prevalence of a condition in the general population. Admissions to Louisville Metro hospitals do not include out-of-state residents. Federal, military, and Department of Veterans Affairs hospitals, state-owned mental hospitals, hospital units of institutions (such as prison hospitals), as well as hospitals with fewer than six beds staffed for patient use, are all excluded.

HEALTHY PEOPLE 2010

When applicable throughout this report, local data is compared to a set of health status indicators from the Healthy People (HP) 2010 national health objectives. Healthy People indicators are established by the U.S. Centers for Disease Control and Prevention (CDC) every ten years. Below is a table that compares major health indicators to HP 2010 objectives.

Table 1. Trends for Louisville Metro Key Health Indicators

HP 2010 Louisville Compared to Compared to Health Indicator Objective Metro HP 2010 Previous Year

Injury Motor Vehicle Crash Death Rate 9.2 16   Unintentional Injury Death Rate 17 56   Suicide Death Rate 4.8 14   Homicide 3 11   Chronic Diseases All Cancers Death Rate 160 256   Lung Cancer Death Rate 44.9 79   Female Breast Cancer Death Rate 22.3 34   Prostate Cancer 28.8 31   Disease of Heart 166 237   Stroke Death Rate 48 67   Diabetes Death Rate 45 35   Maternal and Child Health Infant Death Rate 4.5 6.7   Birth Rate to Teens Aged 15-19 NRG 50.6 -  Percentage Low Birth weight Infants 5 9.1   Communicable Disease AIDS Incidence Rate 1 18.2   Tuberculosis Incidence Rate 1 3.5   Primary or Secondary Syphilis 0.2 5.7   Gonorrhea 19 259   Chlamydia NRG 561 -  Pertussis NRG 3.9 -  NRG = No Related Goal

 = Increase

 = Decrease

 = Inconclusive; No clear trend

DEMOGRAPHIC AND SOCIO-ECONOMIC PROFILE

In 2003, the city of Louisville and Jefferson County (along with its 83 sub-urban incorporated cities) merged to create a consolidated local government and became Louisville Metro. As a result of this merger, population increased from 256,231 to 693,784 according to the 2000 U.S. Census.1

Figure 1.

Overall, Louisville has experienced a slow but steady population growth over the past ten years. By 2010, population for Louisville Metro increased to 741,096. While the white population has decreased by 1.4%, other racial and ethnic groups showed significant increase over the same time period. Between 2000 and 2010, the black population increased by 17% and the Hispanic population has more than doubled.

Figure 2. Decennial Population Trends Louisville Metro

760,000 740,000 720,000 741,096 700,000

680,000 693,604 Population 660,000 664,973 640,000 620,000 1990 2000 2010 Year

Source: U.S. Census Bureau

Figure 3. Population Trends of Non-Hispanic Whites Louisville Metro

545,000 541,602 540,000

535,000 530,056 530,000

525,000 522,561 Population 520,000

515,000

510,000 1990 2000 2010 Year Source: U.S. Census Bureau

Figure 4. Population Trends of Non-Hispanic Blacks, Louisville Metro

180,000 160,000 152,451 140,000 130,003 120,000 112,951 100,000

80,000 Population 60,000 40,000 20,000 0 1990 2000 2010 Year

Source: U.S. Census Bureau

Figure 5. Population trends of Hispanics Louisville Metro

35,000 32,542

30,000

25,000

20,000

Population 15,000 12,370

10,000 4,365 5,000

0 1990 2000 2010 Year Source: U.S. Census Bureau

RACE AND ETHNICITY

Following national trends, the proportion of non-white residents in Louisville Metro continues to increase since 1990. According to the 2010 U.S. Census, Louisville Metro has a non-white population of 30%, with the largest portion being non-Hispanic black (21%). While 4% of Louisville Metro residents are of Hispanic or Latino origin, the remainder of the immigrant population is largely made up of groups from Africa, Asia and the Pacific Islands (5%).

Figure 6. Population by Race/Ethnicity, 2010

4% 5%

21% White (Non-Hispanic) Black (Non-Hispanic) Hispanic or Latino Other (Non-Hispanic) 70%

Source: U.S. Census Bureau

LANGUAGES SPOKEN

The percent of residents of Louisville Metro who do not speak English well or at all was estimated to be 1.6% in 2009, an increase from 1.2% reported in 2000. However, 7.4% of all residents speak a language other than English at home with the most common language being Spanish. In addition to Spanish, the next top five languages spoken by the Louisville Metro immigrant community included French (or Creole), German, Slavic languages such as Russian or Polish, Korean and Vietnamese. Indo-European languages can include languages of India including Hindi, as well as Baltic, Greek and Iranian languages.2 The number of Louisville Metro residents that speak Indo-European languages combined is 12,976 and Asian/Pacific Islander languages combined is 8,235.

Table 2. Number of Louisville Metro Residents Speaking Languages Other Than English 2009 Estimates Estimate Margin of Error Total: 670,594 +/-181 Speak only English 620,811 +/-4,082 Spanish or Spanish Creole 23,087 +/-1,917 Slavic languages 4,184 +/-1,707 Other Indo-European languages 3,888 +/-1,576 French (including Patois, Creole, Cajun) 2,710 +/-1,620 German or other West Germanic languages 2,194 +/-696 Vietnamese 2,123 +/-1,414 Korean 1,899 +/-1,204 Chinese 1,354 +/-821 Tagalog 620 +/-697 Other Asian and Pacific Island languages 2,239 +/-944

Other and unspecified languages 5,485 +/-2,013 Source: U.S. Census Bureau, 2009 American Community Survey

Figure 7. Number of Louisville Metro Residents Speaking Language Other than English at Home, 2009 Estimates Population 25,000 23,087

20,000

15,000 12,976

10,000 8,235 5,485 5,000

0 Spanish Indo-European Asian and Pacific Other Languages Islander Languages (combined) Source: U.S. Census Bureau, 2009 American Community Survey

AGE

In 2010, the largest group of residents in Louisville Metro by age is the 45 to 54 age group followed by the 25 to 34 age group. Since 2000, the age group of 35 to 44 decreased by 15% (95,930), while those in the age group 55 to 64 increased by 51% (91,401). The median age for Louisville Metro population is 37.9 years.

Figure 8. Louisville Metro Population by Age

120,000 2000 100,000 2010 80,000

60,000 Population

40,000

20,000

0 0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Age in Years

Source: U.S. Census Bureau

ECONOMIC STATUS

The median household income in Louisville Metro in 2009 was $44,437 which is 11% lower than the median income for the nation of $50,221. Approximately a third of the Louisville Metro households have annual incomes under $25,000. According to 2009 U.S. Census estimates, Louisville Metro has higher percentages of household incomes under $50,000 compared to the nation.

Figure 9. Annual Household Income, 2009

35.0 Louisville Metro

30.0 Kentucky

25.0 United States

20.0

15.0

10.0 Percentage Percentage Households

5.0

0.0 Under $25,000 $25,000 - $49,999 $50,000 - $74,999 $75,000 - $99,999 Over $100,000

Annual Income

Source: U.S. Census Bureau

Federal poverty thresholds are defined by the U.S. Department of Health and Human Services and vary by size and composition of the household. In 2009, a family of four was considered living below poverty level if their household income was less than $22,050.3 According to the 2009 U.S. Census, approximately 4.8% of Louisville Metro families with children ages 5 to 17 were living below poverty, compared to 10.7% for Kentucky and 10.6% for the nation. A higher percentage of black and Hispanic households have incomes below $25,000 than white households in Louisville Metro.

Figure 10. Annual Household Incomeby Race/Ethnicity Louisville Metro, 2009 White

50.0 46.1 Black 45.0 Hispanic 40.0 34.9 35.0 28.7 30.0 26.6 27.5 23.8 25.0 19.0 19.4 20.0 15.2 15.5 Percent Households Percent 15.0 11.8 9.2 10.0 7.9 5.7 5.6 5.0 0.0 Under $25,000 $25,000 - $49,999 $50,000 - $74,999 $75,000 - $99,999 Over $100,000

Annual Income

Source: U.S. Census Bureau

EDUCATION

Educational attainment of Louisville Metro residents has closer resemblance that of the nation than the state. According to 2009 estimates, 28.9% of Louisville Metro residents have at least a high school degree compared to U.S. with 28.5%. Approximately 8.3% of Louisville Metro residents 25 years and older did not earn a high school diploma, compared to 19% of the state. Louisville Metro had higher percentages of residents with some college education or degrees compared to the state and the nation. However, there are more than twice as many whites with Bachelor degrees compared to black and Hispanic.

Figure 11. Educational Attainment Among Adults Aged 25 and Older Louisville Metro, 2009 Estimates

Louisville Metro

40 Kentucky 34 35 United States 28.9 28.5 30 25 22.5 20 21.3 19 18.4 20 17.6 14.8 13 15 11.3 10.3 8.3 9 10 7 7 7.5

Percentage Percentage Population 5 0 No High High School Some College, Associate's Bachelor's Graduate or School Graduate No Degree Degree Degree Professional Diploma Degree Source: U.S Census Bureau

Figure 12. Educational Attainment Among Adults Aged 25 and Older by Race and Ethnicity, Louisville Metro, 2009 Estimates

35.0 33.2 White 30.0 28.2 29.0 26.0 26.0 Black 25.0 Hispanic 21.4 20.5 20.0 15.6 15.9 15.0 12.0 11.0 9.9 10.0 7.7 8.3 7.4 6.9 6.2

Percentage Population Percentage 5.0 1.4 0.0 No High School High School Some College, Associate's Bachelor's Graduate or Diploma Graduate No Degree Degree Degree Professional Degree

Source: U.S Census Bureau

UNEMPLOYMENT

While the nation’s unemployment rate has nearly doubled over the past ten years, so has that of the Louisville Metro area; however, the unemployment rate for Louisville Metro has remained slightly higher compared to the U.S. since 2004. In 2000, the annual unemployment rate in Louisville Metro was 3.6. As of 2010, the unemployment rate for Louisville Metro was 10.6, compared to 9.6 for the nation.

Figure 13. Annual Unemployment Rates Rate 12

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Louisville Metro United States

Source: Kentucky Department for Workforce Investment

HEALTH CARE COVERAGE

According to the 2009 Behavioral Risk Surveillance System (BRFSS) survey, the percentage of adults having health care coverage in Louisville Metro was higher than the state and nation. The percentage of adults with health care overage rose from 85% in 2004 to 89% in 2009.

Figure 14. Percent Adults With Any Type of Health Care Coverage BRFSS 2004 Percent 2009 90 89 89

86 85 86 85 85 85 84 84

82 Louisville Metro Kentucky United States

Sources: Kentucky Department for Public Health; U.S. Centers for Disease Control and Prevention

MATERNAL AND CHILD HEALTH

BIRTH RATE

There were 9,815 live births in Louisville Metro in 2009. Most of these births occurred to white women, followed by black women (27.1%) and those of Hispanic ethnicity (7.1%).

Birth rate is calculated as the number of births per 1,000 people. The birth rate was 14.2 live births per 1,000 people in 2009, with the highest birth rate occurring among Asian and Pacific Islander women (30.8), followed by black women (20.3) and white women (11.4).

Table 3. Select Characteristics of Live Births to Louisville Metro Residents, 2000-2009 Births % Birth Rate* Year 2000 10,120 14.6 2001 9,777 14.1 2002 9,708 14.0 2003 9,788 14.1 2004 9,896 14.3 2005 9,878 14.2 2006 10,353 14.9 2007*** 10,628 15.3 2008*** 10,554 15.2 2009*** 9,815 14.2 Race of Mother White 6100 62.1% 11.4 Black 2659 27.1% 20.3 Asian/ Pacific Islander 305 3.1% 30.8 American Indian 11 0.1% 7.2 Other/Unknown 36 0.4% 2.5 Ethnicity of Mother Non-Hispanic 9,114 92.9% Hispanic 697 7.1% Age of Mother (years) 15-19 1,113 11.3% 50.6** 20-34 7,548 76.9% 104.8** 35-44 1,116 11.4% 19.2** Mothers with high school 7,761 79.1% diploma or higher Source: Louisville Metro Birth Records, Kentucky Department of Public Health * Births per 1,000 population. Rates calculated using U.S Census 2000 data. ** Births per 1,000 women in that age group *** Preliminary data

Approximately three-quarters of the live births (76.8%) were to women 20 to 34 years of age. Teenage females (age 15 to 19) accounted for 11.3% of the live births. Although teen birth rates saw a decline between 1999 and 2004, birth rates among this group have since increased from 43.5 in 2004 to 50.6 in 2009. Approximately 80% of mothers that gave birth in 2009 were high school graduates.

Figure 15. Birth Rates for Teenage Females 15-19 Years of Age in Kentucky and Louisville Metro, 1999-2009

Births per 1,000 females age 15-19 80

Louisville 60

40 Kentucky

0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Louisville Metro Birth Records, Kentucky Department for Public Health

Figure 16. Birth Rates for Females Between 15-19 years Age Louisville Metro, 2009 Borths per 1,000 Females Age 15 to 19 64.0 55.1 50.6 48.0 42.5

32.0

16.0

0.0 Louisville Metro Kentucky USA

Source: Louisville Metro Birth Records, Kentucky Department for Public Health

INFANT MORTALITY

What is it?

Infant mortality is the death of an infant before the date of the first birthday. The infant mortality rate (IMR) is calculated by dividing the number of newborns dying under a year of age by the number of live births during the year. The IMR is reported as the number of live newborns dying under a year of age per 1,000 live births.

Why is it important?

Infant mortality is an important indicator of the health of a community and its mothers. There are many factors that affect infant deaths including the health of a pregnant woman, their ability to access prenatal care, the care that they receive during and after delivery, care provided to the newborn and the care the infant receives when he/she goes home.4

What’s Louisville Metro’s status?

The IMR for Louisville Metro in 2009 was 6.7 deaths per 1,000 live births. This rate was higher than the reported rate for the state (6.45) and the nation (6.42). It also exceeded the Healthy People 2010 goal of no more than 4.5 deaths per 1,000 live births. IMR among whites was lower than the rate for blacks (6.7 per 1,000 live births compared to 7.5). In 2009, a total of 66 infants died before their first birthday in Louisville Metro. Of the infants who died, 62% were white, 30% black, and 4.6% were Hispanic.

Figure 17. Infant Mortality Rate Louisville Metro, 2009 Rate per 1,000 Live Births Healthy People 2010 Goal = 4.5 8.0 6.7 6.5 6.4 6.0

4.0

2.0

0.0 Louisville Metro Kentucky USA Source: 2009 Louisville Metro Birth Records, Kentucky Department for Public Health; National Vital Statistics Reports, U.S. Centers for Disease Control and Prevention

Figure 18. Infant Mortality by Race

Black White 8.0 7.5 6.7

6.0

4.0

2.0

0.0 Black White

Source: 2009 Louisville Metro Birth Records, Kentucky Department for Public Health

Figure 19. Percentage of Infant Mortality by Race, Louisville Metro, 2009

Percentage 70.0 65.1 60.0 50.0

40.0 31.8 30.0 20.0

10.0 3.2 0.0 white Black Other Source: 2009 Louisville Metro Birth Records, Kentucky Department for Public Health

LOW BIRTH WEIGHT

What is it?

Babies who are low birth weight (LBW) weigh less than 2500 grams (or 5.5 pounds) at birth. Very low birth weight (VLBW) babies are classified as those weighing less than 1500 grams (or 3.3 pounds).

Why is it important?

Birth weight is an important indicator of infant health. Children born with a very low birth weight are more likely to die in the first year of life than children of a healthy birth weight and those who survive face a higher risk for health complications. Low birth weight is the leading cause of infant death in the U.S.5 As a group, LBW children experience more health problems, such as asthma, upper and lower respiratory infections, and ear infections.6 Additionally, LBW children are at risk for lower scores on intelligence tests and for developmental delays.

There are also several social and medical factors that contribute to the risk of a low birth weight infant. Most important among these are pre-term (or early) labor and delivery, pregnancy associated hypertension (high blood pressure), maternal smoking and illicit drug use, young age of mother, poverty, decreased access to care, increased stress, poor maternal nutrition and the mother’s level of education.7

What is Louisville Metro’s status?

In 2009, 9% (or 894) of the 9815 live births in Louisville Metro were classified as low birth weight (LBW) and of these, 207 (or 21%) were very low birth weight (VLBW). The percentage of low birth weight infants in Louisville Metro (9.1%) was higher than state (8.8%) or national rate (8.2%). This rate also exceeded the Healthy People 2010 goal of 5%. The highest percentage of low birth weight babies was among black mothers (13%). White percentage of low birth weight babies was 7.6% and it was 8.8% for the all the other race combined category.

Figure 20. Percent Low Birth Weight, 2009 Percentage

14 13.1

12 Healthy People 2010 Goal = 5.0 10 8.8 9.1 8.8 8.2 7.6 8 7

0 LM White LM Black LM Other LM Hispanic Louisville Kentucky USA (2008) Metro

Source: 2009 Louisville Metro Birth Records, Kentucky Department for Public Health; 2008 National Vital Statistics Report, U.S. Centers for Disease Control and Prevention

As a group, mothers 19 years of age and under have the highest percentage of LBW infants (10.1%), followed by mothers 35 years of age and older (9.2%). The percentage of low birth weight births by mothers belonging to all age groups decreased from the previous years.

Approximately 71% of LBW infants born in Louisville Metro were pre-term (or premature) births. This was a 12% increase from the previous year.

Figure 21. Percent Low Birth Weight by Age of Mother, Louisville Metro, 2009

Percentage 10.1 10.0 8.9 9.2

8.0

6.0

4.0

2.0

0.0 19 and under 20 to 34 35 and older

Source: 2009 Louisville Metro Birth Records, Kentucky Department for Public Health

SMOKING DURING PREGNANCY AND LOW BIRTH WEIGHT

Of the 54 largest metropolitan areas in the U.S., the percentage of women who smoke during pregnancy in Louisville Metro has been reported as among the highest.8 Approximately one quarter of the women who gave birth to a low birth weight infant in Louisville Metro in 2009 reported smoking during the last three months of pregnancy. This far exceeded the Healthy People goal of 99% of females abstaining from cigarette smoking while pregnant.

Figure 22. Smoking Status of Mother for Low Birth Weight Infants, Louisville Metro, 2009

Mother Smoked 24%

Mother did not smoke 76%

Source: 2009 Louisville Metro Birth Records, Kentucky Department for Public Health

PRENATAL CARE

What is it?

Prenatal care is defined as health care and other services available to women during pregnancy. Adequate prenatal care is usually defined as starting care in the first three months (first trimester) of pregnancy with at least nine (9) visits for women giving birth to full-term infants (after 37 weeks of pregnancy).9

Why is it important?

It is important that mothers receive adequate prenatal care because it provides an opportunity to identify and treat problems early, improving the birth outcome. The purpose of prenatal care is to decrease the number of infants born too early (pre-term birth) and too small (low birth weight), and to prevent mother and infant sickness and death.

What is Louisville Metro’s status?

Approximately 25% of Louisville Metro and 27.5% of Kentucky women who gave birth did not receive prenatal care during the first trimester in 2009. Both the Louisville Metro and state rates exceed the Healthy People 2010 goal of not more than 10% of pregnant women failing to receive prenatal care in the first trimester. Women of color were less likely to receive prenatal care. In 2009, black (38%) had the highest number of mothers that did not receive prenatal care in the first trimester, followed by Hispanics (31.4%).

Figure 23. Percentage of Mothers Not Receiving Prenatal Care in First Trimester by Race and Ethnicity, Louisville Metro, 2009 Percentage

40.0 38.0

31.4 30.0 24.5 22.2 20.0 17.8

10.0

0.0 Black White Other Hispanic Louisville Metro

Source: 2009 Louisville Metro Birth Records, Kentucky Department for Public Health

Women 19 years of age or younger were the least likely to receive prenatal care during the first trimester, with 38.4% not receiving such care. Women 35 years of age and older were most likely to receive prenatal care, with only 19.6% not receiving care during the first trimester.

Figure 24. Percentage of Mothers Not Receiving Prenatal Care in First Trimester by Age, Louisville Metro, 2009

Percentage 50.0

40.0 38.4

30.0 23.1 19.6 20.0

10.0

0.0 15 to 19 20 to 34 35 to 54 Age of the Mother

Source: 2009 Louisville Metro Birth Records, Kentucky Department for Public Health

TEEN BIRTHS

What is it?

The teen birth rate is defined as the number of live births per 1,000 women 15 to 19 years of age. It is important to note that teen pregnancy rates differ from teen birth rates. Teen pregnancy rates represent the number of live births, induced abortions, and fetal deaths combined.

Why is it important?

High teen birth rates are an important concern for a community because teen mothers and their babies face increased health risks and diminished opportunities to build a future. Babies born to teenage mothers face a higher risk for premature birth, low birth weight, developmental problems and death.

Teen births can have adverse long-term social and economic impacts on teen parents, their children and the community. According to CDC, children of teenage mothers are more likely to have lower school achievement and drop out of high school, have more health problems, be incarcerated at some time during adolescence, give birth as a teenager, and face unemployment as a young adult.10

What is Louisville Metro’s status?

The teen birth rate in the Louisville Metro is 50.6. This is lower than the state (55.1), but remained higher than the national rate (42.5) in 2009.

Figure 25. Birth Rates for Females Between 15-19 years Age Louisville Metro, 2009 Borths per 1,000 Females Age 15 to 19 64.0 55.1 50.6 48.0 42.5

32.0

16.0

0.0 Louisville Metro Kentucky USA Source: 2009 Louisville Metro Preliminary Birth Records, Kentucky Department for Public Health

Figure 26. Birth Rate Trends for Teenage Females 15-19 Years of Age by Race, Louisville Metro White Births per 1,000 females age 15-19 Black 97.6 99.5 100 94.3 90.7 90 77.7 80 75.5 70 60 50 36.5 40 35.4 34.4 33.6 30.9 32.6 30 20 10 0 2004 2005 2006 2007 2008 2009 Year

Source: Louisville Metro Birth Records, Kentucky Department for Public Health

FIGURE 27. Birth Rates for Teenage Females 15-19 Years of Age in Kentucky and Louisville Metro, 1999-2009

Births per 1,000 females age 15-19 80

Louisville 60

40 Kentucky

0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: 2009 Louisville Metro Preliminary Birth Records, Kentucky Department for Public Health

CHILDHOOD LEAD EXPOSURE

What is it?

Children with blood lead levels (BLLs) greater than or equal to 10 micrograms of lead per deciliter of blood (µg/dL) are considered having elevated blood lead levels.

Why is it important?

Approximately 250,000 U.S. children aged 1-5 years have blood lead levels greater than 10 micrograms of lead per deciliter of blood.11 Elevated lead blood levels in children are associated with adverse effects including abnormal cognitive development, behavior problems, decreased intelligence and poor school performance.12

Lead poisoning is a result of ingestion or inhalation of lead based paint. For young children, exposure to lead is most frequently from dust and paint chips from old surfaces painted with lead- based paint, most commonly where they live and play. Therefore, children who reside in older housing are at greater risk of becoming lead poisoned. Age and condition of housing units, not the geographic location, are the most important predictors for the presence of hazards related to lead- based paint.

In 1997, CDC proposed new guidelines recommending state and local health officials target their efforts to children who live in older homes and children from low-income families, including children who receive Medicaid benefits. Although young children living in poverty are at a higher risk for elevated BLLs, lead poisoning is an issue that crosses all socioeconomic groups, geographic locations, racial and ethnic populations.

What’s Louisville Metro’s Status?

A total of 21,867 children were screened by the health department’s Childhood Lead Poisoning Prevention Program in 2009 and 2010. The percentage of children screened with blood levels equal or greater than 10 µg/dL has decreased from 10% in 2000 to 1.6% in 2009. While an increase occurred in 2005, with 4.7% of the children exhibiting elevated blood lead levels, the percentage began to decline again during subsequent years.

Figure 28. Precent of Children (≤ 72 months of age) Screened with Blood Lead Levels at or Above Percent 10 mcg/dL in Louisville Metro, 2000-2010 12

10.0 10 8.8

6 5.6 4.7 3.8 4 3.1 2.7 2.1 1.9 1.6 2 1.2

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Source: Childhood Lead Poisoning Prevention Program, LMPHW

Figure 29. Mean Blood Lead Levels µg/dL Louisville Metro, 2000-2010 6 5.4 5.2

5 4.4 3.8 3.7 4 3.5 3.0 3 2.3 2.2 2.2 1.7 2

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Source: Childhood Lead Poisoning Prevention Program, LMPHW

The mean blood lead levels in Louisville Metro have steadily declined over the past decade. This is true for both whites and blacks. Although the disparity between whites and blacks has narrowed over the past several years, mean blood lead levels for blacks remain consistently higher than that of whites.

Figure 30. Mean Blood Lead Levels by Race Louisville Metro, 2000-2010 Percent 7 White 6.0 5.9 6 Black 4.9 5 4.5 5.3 4.2 4.2 4.9 4 3.4 4.3 2.6 3 3.6 3.5 2.3 2.3 3.2 1.7 2 2.7 2.0 1.9 2.1 1 1.5

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Source: Childhood Lead Poisoning Prevention Program, LMPHW

HOSPITAL DATA

What is it?

An inpatient discharge occurs when a patient is admitted overnight to a hospital and leaves that hospital. Thus, an individual who is transferred from hospital A to hospital B would be included in the discharges from hospital A with a second discharge from hospital B.

Why is it important?

Hospital data provides valuable information regarding the most frequent health conditions residents are diagnosed when they are admitted to local hospitals. This information helps to identify and prioritize health issues for the community, design public health programs and develop public health policy.

What’s Louisville Metro’s status?

The top primary health condition responsible for inpatient hospitalizations in 2009 was heart disease (1447), followed by mental or emotional illness (988). COPD, cancer and stroke were the remaining leading conditions for inpatient hospitalization. The leading health condition for whites (1604) and blacks (1230) was heart disease and the leading cause of hospitalization for Hispanics (532) was mental or emotional illness. Mental or emotional diagnosis was the second leading cause for inpatient hospitalization for whites and blacks.

Figure 31. Top 10 Primary Health Conditions Responsible for Inpatient Hospitalizations (Rate per 100,000), Jefferson County, 2009

Heart Disease 1447

Mental or Emotional Diagnosis 988

COPD 521 Rate Rate per 100,000

Cancer (Malignant Neoplasms) 444

Stroke 350

Asthma 213 Population

Diabetes 205

Drug induced morbidity 201

Alcohol induced morbidity 143

Hypertension 97

Source: Kentucky Inpatient Hospitalization Claims Files, Kentucky Department for Public Health

Figure 32. Top 10 Primary Health Conditions Responsible for Inpatient Hospitalization by Race and Ethnicity (Rate per 100,000), Jefferson County, 2009 1604 Heart Disease 1230 177 Mental or Emotional 1005 1039 Diagnosis 532 495 COPD 736 131 145 Asthma 496 100 Cancer (Malignant 504 White 314 Neoplasms) 66 Black 386 Stroke 314 42 Hispanic 180 Diabetes 314 35 225 Drug induced morbidity 136 143 78 Perinatal conditions 185 108 77 Hypertension 196 8 Rate per 100,000 Population Source: Kentucky Inpatient Hospitalization Claims Files, Kentucky Department for Public Health

The leading four causes for inpatient hospitalization among Louisville Metro residents below 20 years of age in 2009 were mental or emotional diagnosis, unintentional injury, COPD and asthma. Childbirth, pregnancy or puerperiums are also leading causes for hospitalization. This is often due to multiple pregnancy, child birth related or neonatal hospital visits throughout a calendar year. However, for youth below the age of 20 the inpatient hospital rate for health conditions related to pregnancy, childbirth or neonatal visits (973) exceeds that of all other conditions other than mental or emotional diagnosis.

For adults above 20 years of age heart disease is the top primary health condition of inpatient hospitalization, followed by mental or emotional diagnosis.

Figure 33. Top 10 Primary Health Conditions Responsible for Inpatient Hospitalizations (Rate per 100,000) Among Youth Below 20 Years Age, Jefferson County, 2009

Mental or Emotional Diagnosis 1024

Unintentional Injury 423 Rate Rate per 100,000 COPD 383

Asthma 381

Perinatal Condition Diagnosis 380

Congenital Anomaly Diagnosis 124 Population Drug induced morbidity 91

Diabetes 73

Motor vehicle crash 51

Suicide and Self Inflicted Injury 39

Source: Kentucky Inpatient Hospitalization Claims Files, Kentucky Department for Public Health

Figure 34. Top 10 Primary Health Conditions Responsible for Inpatient Hospitalizations (Rate per 100,000) Among Adults Over 21 Years Age, Jefferson County, 2009

Heart Disease 1980

Mental or Emotional Diagnosis 974 Rate Rate per 100,000 Cancer (Malignant Neoplasms) 600

COPD 573

Stroke 478

Diabetes 254 Population Drug induced morbidity 243

Alcohol induced morbidity 191

Asthma 150

Hypertension 132

Source: Kentucky Inpatient Hospitalization Claims Files, Kentucky Department for Public Health

CAUSES OF DEATH

The total number of deaths in Louisville Metro in 2009 was 8,177. The age-adjusted death rate from all causes was 1136.7 per 100,000 population. This rate was higher than the state (878.6) and national (741.0) rates. The age-adjusted death rate from all causes for Louisville Metro blacks was 17% higher than the rate for Louisville Metro whites.

Figure 35. Age-Adjusted Death Rates from All Causes, Louisville-Jefferson County, 2009 Age-Adjusted Rate per 100,000 1600.0 1349.8 1400.0

1200.0 1110.0 1136.7

1000.0 878.6 800.0 741.0

600.0

400.0

200.0

0.0 LM Blacks LM Whites Louisville Kentucky United States Metro

Source: 2009 Louisville Metro Death Records, Kentucky Department for Public Health; National Center for Health Statistics

In 2009, the male age-adjusted death rate was 36.5% higher than the rate for females (1463 compared to 928.5 per 100,000 population). Louisville Metro death rates for both genders, however, were higher than both the state and national death rates.

Figure 36. Age-Adjusted Death Rate From All Causes by Gender, Jefferson County, 2009 Age-Adjusted Rate per 100,000 Male 1600 1463 Female 1400

1200 1043 1000 929 906 749 800 643 600 400 200 0 Louisville Metro Kentucky United States

Source: 2009 Louisville Metro Death Records, Kentucky Department for Public Health, National Center for Health Statistics

LEADING CAUSES OF DEATH

Malignant neoplasm, commonly known as cancer, was the number one cause of death in Louisville Metro during 2009, accounting for 23% of all deaths. In addition to cancer, the other top causes of death are heart disease, chronic lower respiratory disease (including COPD), stroke/cerebrovascular disease and unintentional injuries.

Figure 37. Percentage of Total Deaths Due to Leading Causes of Death Louisville Metro, 2009

Malignant Neoplasms (All cancers 2% 3% combined) 3% Diseases of Heart 3% Chronic Lower Respiratory 23% 3% Disease Stroke/Cerebrovascular Disease

5% Unitentional Injury

Alzheimer's Disease

6% Diabetes

Septicemia 6% Nephritis, Nephrotic Syndrome & Nephrosis 21% Influenza & Pneumonia

Source: 2009 Louisville Metro Death Records, Kentucky Department for Public Health

Figure 38. Leading Causes of Death by Gender Louisville Metro, 2009

Age-Adjusted Rate per 100,000 Male 350 331 327 Female 300

250 213 200 176

150

100 86 80 78 61 60 50 37

0 Malignant Disease of Heart Chronic Lower Unintentional Cerebrovascular Neoplasms Respiratory Injuries Disease Disease

Source: 2009 Louisville Metro Death Records, Kentucky Department for Public Health

Louisville metro males had higher death rates than females for each of the top five causes of death in Louisville Metro during 2009. Blacks had a higher death rate from malignant neoplasms (cancers), heart disease and stroke/cerebrovascular disease, while whites had higher rates in chronic lower respiratory disease (including COPD) and unintentional injuries.

Figure 39. Leading Causes of Death by Race Louisville Metro, 2009 Age-Adjusted Rate per 100,000

350 327 309 White 300 250 250 227 Black

200

150

100 72 67 73 57 44 48 50

0 Malignant Diseases of Chronic Lower Cerebrovascular Unintentional Neoplasms Heart Respiratory Disease Injuries Disease Source: 2009 Louisville Metro Death Records, Kentucky Department for Public Health

CHRONIC DISEASES

DISEASE OF THE HEART

What is it?

Diseases of the heart consist of a variety of disorders and conditions including coronary heart disease, hypertensive heart disease, arrhythmia (irregularity in heartbeats), and cardiomyopathy (enlargement of the heart).13

Coronary heart disease is the most common type of diseases of the heart. The word ‘coronary’ means crown and is the name given to the arteries that circle the heart like a crown.14 The coronary arteries supply the heart muscle with oxygen and nutrients. Coronary heart disease develops when one or more of the coronary arteries that supply the blood to the heart become narrowed, impairing the blood flow to the heart muscle. This occurs due to a buildup of cholesterol or other fatty substances in the blood vessels of the heart.

Why is it important?

Coronary heart disease is the nation’s leading cause of death, killing more than one in every four of Americans.15 There are several risk factors associated with heart disease. Some of these risk factors can be modified, treated or controlled while others cannot. Risk factors that cannot be controlled include heredity, age and gender. Research has shown that men have a greater risk of heart attack than women, and over 80% of deaths from heart disease occur among people that are 65 years or older.16 Risk factors that can be modified and controlled include smoking, lack of exercise, stress and obesity. Obesity increases blood pressure, blood cholesterol levels, risk of diabetes and other conditions that directly contribute to heart disease. Stress is also known to be a contributing factor. Healthy diet and regular exercise are proven lifestyle changes known to decrease the risk of heart disease.

What is Louisville Metro’s status?

In 2009, the age-adjusted rate of death for diseases of the heart in Louisville Metro (237 per 100,000) was higher than Kentucky’s rate of 201, as well as the Healthy People 2010 goal (166 deaths per 100,000) and the national rate (180).

The age-adjusted death rate for heart disease among Louisville Metro blacks (309 per 100,000) continues to be higher than the rate for Louisville Metro whites (227 per 100,000). When compared to 2008, the death rate from heart disease for blacks increased to 309 (compared to 283) and for whites it decreased to 227 (compared to 243) in 2009. From 1999 to 2006, the age-adjusted death rate for diseases of the heart gradually declined, but began to rise again thereafter.

Figure 40. Age-Adjusted Death Rates for Disease of the Heart, 2009 Death Rate per 100,000 Population Healthy People 2010 350 327 309 Goal = 166 300 237 250 227 201 200 176 180 150 100 50 0 LM Blacks LM Whites LM Male LM Female Louisville Kentucky United Metro States Source: 2009 Louisville Metro Death Records, Kentucky Department for Public Health; National Center for Health Statistics

Figure 41. Age-Adjusted Death Rates from Diseases of the Heart, Louisville Metro 1999-2009 Death Rate per 100,000 Population 350 315 304 289 287 300 270 249 247 235 244 237 250 216

200

150

100

0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: 2009 Louisville Metro Death Records, Kentucky Department for Public Health; National Center for Health Statistics

According to the 2009 Behavioral Risk Factor Surveillance System (BRFSS), 4.6% of Louisville Metro respondents of the survey reported having a heart attack. While this was lower than the state, it was higher than the U.S. percentage in the same year. Common risk factors associated with cardiovascular disease include high blood pressure and high cholesterol. Thirty-seven percent of respondents reported that they have been told by a doctor that they have high blood pressure and 36.8% reported having high cholesterol levels.

Figure 42. Percent Adults Ever Had Heart Attack, BRFSS, 2009

Percent 7.0 5.9 6.0

5.0 4.6 4.0 4.0

3.0

2.0

1.0

0.0 Louisville Metro Kentucky United States Source: 2009 Behavioral Risk Factor Surveillance System, Kentucky Department for Public Health; National Center for Health Statistics

Figure 43. Percent Adults Ever Told They Have High Blood Pressure, BRFSS, 2009 Percent 40.0 37.5 36.4 35.0 28.7 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Louisville Metro Kentucky United States

Source: 2009 Behavioral Risk Factor Surveillance System, Kentucky Department for Public Health; National Center for Health Statistics

Figure 44. Percent Adults Ever Told They Have High Blood Cholesterol, BRFSS, 2009 Percent 42.0 41.6 41.0 40.0 39.0 38.0 37.5 36.8 37.0 36.0 35.0 34.0 Louisville Metro Kentucky United States

Source: 2009 Behavioral Risk Factor Surveillance System, Kentucky Department for Public Health; National Center for Health Statistics

CANCER

What is it?

Malignant neoplasms, commonly known as cancer, are diseases in which abnormal cells divide without control and are able to invade other tissues. Cancer cells can spread to other parts of the body through the blood and lymph systems. There are over 100 different types of cancer.17

Why is it important?

Cancer is the second leading cause of death in the U.S. An estimated 570,000 cancer deaths and over 1.5 million new cases of cancer were reported in 2011.18 The three most common cancers among men are prostate cancer, lung cancer and colorectal cancer. For women, the most common cancers are breast cancer, lung cancer and colorectal cancer. Lung cancer is the leading cause of cancer death for both genders in the country.

About 30% of cancer deaths are due to five leading behavioral and dietary risks. They are obesity, low fruit and vegetable intake, lack of physical activity, tobacco use and alcohol use. Avoiding excessive exposure to ultraviolet rays from the sun and tanning beds can help reduce the risk of skin cancer. For some cancers such as colorectal and breast cancer early screenings have been proven to prevent deaths. Vaccines can also help reduce cancer risk. For example, the human papillomavirus (HPV) vaccine helps prevent most cervical cancers and some vaginal and vulvar cancers, and the hepatitis B vaccine may reduce liver cancer risk. CDC has identified regular cancer screenings, information about cancer and referral services that are available and accessible as effective strategies to reduce cancer incidence and deaths.

What’s Louisville Metro’s Status?

In 2009, the age-adjusted rate of death from all cancer deaths combined in Louisville Metro (256 per 100,000) was higher than Kentucky’s rate of 201. This rate is higher than the Healthy People 2010 goal of no more than 160 deaths per 100,000 and the national rate of 174. Although there are more than 100 different types of known cancers, cancer of the lung/bronchus, prostate and breast are the most prevalent.

Figure 45. Age-Adjusted Death Rate for Cancers (Malignant Neoplasms) , 2009 Death Rate per 100,000 Population Healthy People 2010 350 327 326 Goal = 160 300 250 256 250 213 201 200 174 150 100 50 0 LM Blacks LM Whites LM Male LM Female Louisville Kentucky United Metro States Source: 2009 Louisville Metro Death Records, Kentucky Department for Public Health; U.S. National Center for Health Statistics

LUNG CANCER

What is it?

Lung cancer is the uncontrolled growth of abnormal cells in the lung. Cells multiply abnormally and form a mass of cells called a tumor. As the tumor grows, it impairs the exchange of oxygen and causes tissue damage.

Why is it important?

More people in the United States die from lung cancer than any other type of cancer.19 The majority of people who develop lung cancer are cigarette smokers. People who smoke are 10 to 20 times more likely to get lung cancer or die from lung cancer than people who do not smoke.20 Non- smokers are also at risk of developing lung cancer from sharing an environment with someone who smokes. An estimated 3,000 non-smokers die from lung cancer as a result of secondhand smoke

49 exposure each year.21 Lung cancer can be prevented through smoking cessation and a healthy diet that consists of a reduction of fat and an increase in fruit and vegetables.

What is Louisville Metro’s status?

The age-adjusted death rate for lung cancer in Louisville Metro decreased from 85 per 100,000 population in 2008 to 79 per 100,000 in 2009. Yet, it remains higher than the age-adjusted rate for the state (68) and approximately 74% higher than the Healthy People 2010 goal (44.9). The age- adjusted death rate from lung cancer among Louisville Metro blacks was higher than Louisville Metro whites (84 compared to 79).

Figure 46. Age-AdjustedDeath Rates for Lung Cancer, 2009

Death Rate per 100,000 Population 120 Healthy People 2010 103 Goal = 44.9 100 84 79 79 80 64 68 60 53

0 LM Blacks LM Whites LM Males LM Females Louisville Kentucky United Metro States

Source: 2009 Louisville Metro Death Records, Kentucky Department for Public Health; National Center for Health Statistics

Figure 47. Age-Adjusted Death Rates from Lung Cancer, Death Rate per Louisville Metro 1999-2009 100,000 Population 90

85 85 82 82 82 80 80 79 80

75 74 75 75 72

65 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: 2009 Louisville Metro Death Records, Kentucky Department for Public Health

BREAST CANCER

What is it?

Female breast cancer is a malignant tumor that starts in the cells of the breast. A malignant tumor is a group of cancer cells that can grow into (invade) surrounding tissues or spread (metastasize) to distant areas of the body. Although breast cancer occurs most often in women, men can also suffer from the disease.

Why is it important?

Breast cancer is the second leading cause of cancer death for women. According to the American Cancer Society, the chance that breast cancer will be responsible for a woman's death is about 1 in 36.22 However, death rates from breast cancer have decreased since 1990. This is particularly true among women under the age of 50 years old. This decline has been attributed to the increase in earlier screenings, public awareness and improved treatment.

What’s Louisville Metro status?

The age-adjusted death rate for female breast cancer in 2009 was 34 deaths per 100,000 female population, meeting the Healthy People 2010 goal of 22.3. However, the age-adjusted death rate for black females (50) was more than a third higher than for whites.

Figure 48. Age-Adjusted Death Rates for Female Breast Cancer, 2009

Death Rate per 100,000 Population 60 Healthy People 2010 Goal = 22.3 50 50

40 34 32 30 23 20 13 10

0 LM Blacks LM Whites LM Females Kentucky United States

Source: 2009 Louisville Metro Death Records, Kentucky Department for Public Health; National Center for Health Statistics

PROSTATE CANCER

What is it?

Prostate cancer forms in tissues of the prostate, occurring most common among older men. The prostate is a gland in the male reproductive system found below the bladder and in front of the rectum.

Why is it important?

Prostate cancer is the second leading cause of cancer deaths among men in the U.S., exceeded only by lung cancer. An estimated 33,720 deaths and 240,000 new cases will occur from prostate cancer by the end of 2011.23 According to the American Cancer Society, more than 2 million men in the U.S. count themselves as prostate cancer survivors.24

Unlike other cancers, there are no definite risk factors known for prostate cancer. However, men 50 years of age or older are at a higher risk of being diagnosed with prostate cancer, as well as African-American men or those that have a close relative who has had prostate cancer.25

What’s Louisville Metro’s status?

The age-adjusted death rate for prostate cancer in Louisville Metro was 31 per 100,000 male population. The rate for black males was double that of white males. The Louisville Metro rate for prostate cancer was also higher than the rate for the state, nation, as well as Healthy People 2010 goal.

Figure 49. Age-Adjusted Death Rates for Prostate Cancer, 2009

Healthy People 2010 Death Rate per Goal = 28.8 100,000 Population

35 31 30 25 25 22 20

15 12 10 9 5 0 LM Black Males LM White Males LM Males Kentucky United States

Source: 2009 Louisville Metro Death Records, Kentucky Department for Public Health; National Center for Health Statistics

COPD

What is it?

Chronic obstructive pulmonary disease, or COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema, chronic bronchitis, and in some cases asthma.

Why is it important?

COPD is the fourth leading cause of death in the United States and causes serious, long-term disability among its survivors. According to the U.S. Centers for Disease Control and Prevention, 120,000 Americans die each year from COPD, and the numbers are increasing.26 Tobacco use is a key factor in the development and progression of COPD; however asthma, exposure to air pollutants in the home and workplace, genetic factors and respiratory infections also play a role.

Early detection of COPD might alter its course and progress. A simple test can be used to measure pulmonary function and detect COPD in current and former smokers aged 45 and over and anyone with respiratory problems. Avoiding tobacco smoke, home and workplace air pollutants, and respiratory infections are all key to preventing the initial development of COPD.

What’s Louisville Metro’s status?

In 2009, the Louisville Metro age-adjusted rate of chronic obstructive pulmonary disease (COPD) deaths was 63 deaths per 100,000 population. However, this rate was almost double for whites than it was for blacks. Local rates were also higher than the state (60 per 100,000 population). Louisville Metro males had higher rates when compared to females (79 compared to 57 per 100,000 population).

Figure 50. Age-Adjusted Death Rates for COPD, 2009

Death Rate per 100,000 Population 90 79 80 68 70 63 57 60 60 50 38 40 30 20 10 0 LM Blacks LM Whites LM Males LM Females Louisville Kentucky Metro

Source: 2009 Louisville Metro Death Records, Kentucky Department for Public Health

STROKE/CEREBROVACULAR DISEASE

What is it?

A stroke, also called a “cerebrovascular accident,” results from an interruption of the blood supply to a portion of the brain.27 A stroke can be due to an insufficient supply of blood caused by a vessel becoming smaller, a blood clot, or an accumulation of fat blocking the vessel. A stroke also can be caused by a blood vessel rupturing that bleeds into the brain. This interruption in blood flow decreases the supply of oxygen and other nutrients to the cells in that part of the brain causing these cells to die.

Why is it important?

Stroke remains the third leading cause of death in the United States.28 Depending on the part of the brain affected, damage can result in the loss of speech, vision, movement in an arm or leg, or even death. While anyone can suffer from a stroke, there are certain factors that increase a person’s risk. Uncontrollable risk factors may include increase in age and having a family history of stroke. Controllable risk factors include smoking, drinking alcohol, being overweight, lack of exercise and unhealthy diet. Taking steps toward a healthier lifestyle such as controlling blood pressure, smoking cessation, eating a healthy diet and regular exercise can lower the chances of suffering from a stroke.

What’s Louisville Metro’s status?

The age-adjusted death rate for stroke, or cerebrovascular disease, was 67 deaths per 100,000 population. This rate exceeds the Healthy People 2010 goal and the state rate of 48 deaths per 100,000 population. Louisville Metro blacks had a higher age-adjusted death rate from stroke (73 per 100,000 population) than whites (67 per 100,000 population).

Figure 51. Age-Adjusted Death Rates for Cerebrovascular Disease/Stroke, 2009 Death Rate per 100,000 Population Healthy People 2010 90 Goal = 48 78 80 73 67 67 70 60 60 50 43 39 40 30 20 10 0 LM Blacks LM Whites LM Males LM Females Louisville Kentucky United Metro States Source: 2009 Louisville Metro Death Records, CHFS Department for Public Health; National Center for Health Statistics

The overall age-adjusted death rate from stroke in Louisville Metro has varied from 1999 to 2009. The rate declined from 2003 to 2006, but returned to higher rates in 2007.

Figure 52. Age-Adjusted Death Rates from Stroke, Death Rate per Louisville Metro 1999-2009 100,000 Population 80 70 68 67 70 64 61 61 60 61 56 60 52 51 50

0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: 1999-2009 Louisville Metro Death Records, Kentucky Department for Public Health

DIABETES

What is it?

Diabetes mellitus is a group of diseases (type I, type II and gestational diabetes) characterized by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. Insulin is a hormone produced by the pancreas to regulate blood sugar. Type I diabetes, often called juvenile diabetes, usually starts early in life. Type II diabetes, sometimes called adult-onset diabetes, accounts for up to 95% of all diagnosed cases of the disease. In people with type II diabetes, the pancreas either produces little or no insulin, or the body does not respond appropriately to the insulin that is produced. Gestational diabetes occurs during pregnancy.

Why is it important?

Diabetes is one of the most preventable leading causes of death. According to the American Diabetes Association, 25.8 million children and adults are living with diabetes in the U.S.29 Diabetes can trigger eye, heart, and kidney diseases, as well as other life-threatening health conditions. Elderly people with diabetes are more susceptible to these complications. Controlling blood glucose, blood pressure, and cholesterol levels can reduce the chance of disability. There were 1.9 million new cases of diabetes in people 20 years and older in 2010.30 Several factors account for this increase in the incidence of diabetes. These include lifestyle and behavioral factors such as a high in fat diet, physical inactivity and obesity.

What’s Louisville Metro’s status?

The age-adjusted diabetes mortality rate was 35 deaths per 100,000 population for Louisville Metro in 2009. This rate was higher than state and national rates of 29 and 21, respectively. For Louisville Metro African Americans, the age-adjusted death rate from diabetes (76 per 100,000 population) was approximately three times the rate for Louisville Metro Whites. The age-adjusted death rate from diabetes was almost twice as high for Louisville Metro males than for females.

Figure 53. Age-Adjusted Death Rates for Diabetes, 2009 Death Rate per 100,000 Population 80 76 Healthy People 2010 70 Goal = 45

50 46

40 35 28 28 29 30 21 20

0 LM Blacks LM Whites LM Males LM Females Louisville Kentucky United Metro States

Source: 2009 Louisville Metro Death Records, CHFS Department for Public Health; National Center for Health Statistics

According to the BRFSS survey, the number Louisville Metro adults that reported having diabetes increased from 6.9% in 2004 to 13.2% in 2009.

Figure 54.

ASTHMA

What is it?

Asthma is a chronic disease of the airways that carry air to the lungs. Asthma causes inflammation of these airways resulting in the obstruction of airflow and mucus production. When this occurs, people can experience episodes of breathlessness, wheezing, and coughing that can be distressing and even fatal.

Why is it important?

According to the U.S. Centers for Disease Control and Prevention, the number of people with asthma in the U.S. grew by 4.3 million from 2001 to 2009.31 About 25 million Americans (8% of the population) had asthma in 2009. Asthma rates are higher among certain racial and ethnic groups. From 2001 to 2009, asthma rates rose among black children by almost 50%. As the number of people living with asthma increases so has the economic burden. Asthma related costs in the U.S. grew from about $53 billion in 2002 to about $56 billion in 2007.

Asthma can have a negative effect on the physical, cognitive, social, and emotional development of a child. It is also the leading cause of school absenteeism. In 2003, an estimated 12.8 million school days were missed due to asthma and it is the third ranking cause of hospitalization among children under 15 years of age.32

Asthma is a lifelong disease that affects the lungs and there is no cure.33 Therefore, effective management is essential. Most people with asthma can control their symptoms and prevent asthma attacks by avoiding asthma triggers and correctly using prescribed medicine, such as inhaled

58 corticosteroids. Triggers for asthma can be found at school, work, home, outdoors, and elsewhere. These triggers can include tobacco smoke, mold, outdoor air pollution, and infections linked to influenza, colds, and other viruses.34

What’s Louisville Metro’s status?

Fifteen percent of Louisville Metro adults participating in the BRFSS survey reported being told that they have asthma by a physician or other health professional. This was slightly higher compared to the state and national percentage.

Figure 55. Percent of Adults Reporting Asthma Percent BRFSS 16 2004 15.0 15.0 14.9 15 2009

15 13.9 14 13.5 14 13.2 13

12 Louisville Metro Kentucky United States

Source: Kentucky Department for Public Health; U.S. Centers for Disease Control and Prevention.

The age-adjusted hospitalization rates for asthma were higher for males than females in Louisville Metro and Kentucky from year 2000 to 2009. In 2000, the age-adjusted asthma hospitalization rate for females was 43 and for males was 136 in Louisville Metro. These rates increased for both genders in 2009 to 50 for females and 154 for males but remained lower than the state rate for females (69) and males (205).

Figure 56. Age Adjusted Asthma Hospitalization Rates (Per 100,000 Population) for Adults, Jefferson County

Male Female

198 183 173 163 155 160 158 159 154 136

59 60 64 52 53 58 50 43 39 42

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Kentucky Department for Public Health

BEHAVIORAL RISK FACTORS

Chronic diseases have certain risk factors associated with them. Modifications in a person’s lifestyle can decrease the risk of some of these factors. The Behavioral Risk Factor Surveillance System (BRFSS) gathers information about these risk factors for Louisville Metro residents from a random telephone survey.

Obesity and Overweight Being overweight increases your risk of having a stroke, heart disease, high blood pressure, and type II diabetes.35 The BRFSS survey asked participants for their height and weight to compute a Body Mass Index (BMI). The BMI is a calculated index that attempts to normalize weight for height as an indirect measurement of body fat. A BMI of 25 to 29 is classified as overweight and a BMI of 30 or more indicates obesity.36

In 2004, 62% percent of Louisville Metro adults indicated they were overweight or obese. This increased to 64.9% in 2009. Thirty-three percent of Louisville Metro adults are obese. This was more than twice the Healthy People 2010 goal (15%).

Figure 57. Percent of Overweight or Obese Adults BRFSS 2004 Percent 2009 68 67.1

66 64.9

64 63.3 63.1 62.0 62

59.9 60

56 Louisville Metro Kentucky United States

Source: Kentucky Department for Public Health; U.S. Centers for Disease Control and Prevention

Physical Activity Moderate exercise (i.e., walking at a brisk pace, bicycling, aerobics or yoga) helps keep blood pressure and cholesterol levels within normal ranges, thereby reducing the risk of heart disease, stroke, and diabetes.37 Obesity occurs when the amount of calories consumed in a diet increases while the level of activity does not. Moderate activity is needed to maintain a healthy weight.

The percentage of Louisville Metro adults engaging in some physical activity outside of work in the past month remained nearly the same from 2004 and 2009. The Healthy People 2010 goal for adults engaging in moderate or vigorous physical activity was 50%.

Figure 58. Percent of Adults Engaging in Physical Activity Outside of Work During the Past Month, BRFSS 2004 Percent 2009 78 77.1

76 75.4

74 73.4 72.4 72 70.1 70 69.5

64 Louisville Metro Kentucky United States

Source: Kentucky Department for Public Health; U.S. Centers for Disease Control and Prevention

Nutrition A diet high in fat and cholesterol increases the risk of heart disease, stroke, and diabetes. For optimal health, it is recommended that you eat five or more servings of fruits and vegetables every day.38 In 2011, the U.S. Department of Agriculture (USDA) modified its nutritional guidelines and replaced the nutritional pyramid with an image of a plate that is divided into four sections – fruits, vegetables, grains and protein. The USDA “My Plate” is intended to be an easier guide to a healthy diet.

The percentage of Louisville Metro residents that reported eating five or more servings of fruits and vegetables each day (23.9%) was greater than the percentages for Kentucky and United States in 2009. While respondents reported eating more fruits and vegetables from 2005 to 2009, the data suggests that the majority of Louisville Metro residents are still not eating the recommended amount.

Figure 59. Percent of Adults who Report Eating 5 or More Fruits and/or Vegetables Daily, BRFSS

2005 Percent 2009 30

25 23.9 23.2 23.4 21.1 20 18.0 16.8

0 Louisville Metro Kentucky United States

Source: Kentucky Department for Public Health; U.S. Centers for Disease Control and Prevention

Cigarette Smoking Cigarette smoking has been linked to heart attacks, strokes, artery disease in the legs, preterm birth and lung cancer.39 Secondhand smoke also can result in the same problems for the person inhaling the smoke from smokers, as well as increased emergency room visits and hospitalizations for children with asthma.

Following the state and national trend, the percent of adults that smoke decreased from 25.5% in 2004 to 23.9% in 2009. This remained above the Healthy People 2010 goal for cigarette smoking prevalence (12%).

Figure 60. Percent of Adults Who Currently Smoke Tobacco BRFSS Percent 2004

30 27.5 25.5 25.6 2009 25 23.9 20.8 20 17.9

0 Louisville Metro Kentucky United States

Source: Kentucky Department for Public Health; Centers for Disease Control and Prevention

MENTAL HEALTH

What is it?

The World Health Organization (WHO) defines mental health as a “state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.”40

Mental health is a term used as in reference to mental illness. Mental illnesses are medical conditions that disrupt a person's thinking, feeling, mood, ability to relate to others and daily functioning. Very often it results in a diminished capacity for coping with the ordinary demands of life and may be caused by a reaction to environmental or internal stresses, genetic factors, biochemical imbalances, or a combination of these factors. There are more than 200 classified forms of mental illness with depression being the most common.41

Why is it important?

According to the U.S. Centers for Disease Control and Prevention, depression will be the second leading cause of disability in the world by the year 2020.42 Research has shown that mental illness, particularly depressive disorders, is related to the occurrence of chronic diseases such as diabetes, cancer and heart disease. It can also be strong drivers of many risk behaviors including smoking, drug use and physical inactivity.43

What is Louisville Metro’s status?

The percentage of adults reporting 14 or more “mentally unhealthy” days increased from 12.7% in 2004 to 15% in 2009. More females (9.4%) reported mentally unhealthy days compared to males (5.2%).

Figure 61. Percent of Adults Reporting 14 or More Mentally Unhealthy Days, Louisville Metro

16 15 14 12.7 12 9.4 10 8 2004 8 2009 6 4.8 5.2 4 2 0 LM Male LM Female Louisville Metro

Source: 2009 Behavioral Risk Factor Surveillance Survey, Kentucky Department for Public Health

INJURY AND VIOLENCE

UNINTENTIONAL INJURIES

Injuries can be “unintentional” or “intentional”. The distinction is whether the person causing the injury did so accidentally or on purpose.

What is it?

An unintentional injury occurs when there is physical or bodily harm that was not purposefully inflicted.

Why is it important?

Unintentional injuries are the leading cause of death among those ages 5 to 34 years old in the U.S. Unintentional injuries include motor vehicle accidents, pedestrian and bicycle collisions, burns, falls, drowning, poisoning and suffocation. Such injuries pose a serious public health concern because they impact premature mortality. Reducing unintentional injuries also create safer communities, resulting in healthier communities.

Unintentional injuries affect not only the individual, but society as well. Medical care, rehabilitation, lost wages and lost productivity associated with injuries costs billions of dollars each year in the U.S. A study released by U.S. Centers for Disease Control and Prevention reported the cost of motor vehicle crash related deaths in Kentucky totaled $871 million in 2005.

What is Louisville Metro’s status?

There were 395 unintentional injury deaths in Louisville Metro in 2009. The age-adjusted mortality rate from unintentional injuries for all ages was 56 deaths per 100,000 population. This was higher than the national rate (37) and the Healthy People 2020 goal of 36 deaths per 100,000 population. For Louisville Metro whites, the age-adjusted death rate was 57 per 100,000 population and for blacks it was 48 per 100,000 population.

Figure 62. Age-Adjusted Death Rates for Unintentional Injuries, 2009 Death Rate per 100,000 Population 90 80 Healthy People 2010 80 Goal = 17 70 60 57 56 51 48 50 40 37 37 30 20 10 0 LM Blacks LM Whites LM Males LM Females Louisville Kentucky United Metro States Source: 2009 Louisville Metro Death Records, Kentucky Department for Public Health; National Center for Health Statistics

For the first half of the past decade, the mortality rate for unintentional injury remained stagnant. The rate peaked from 39.7 in 2006 to 58.2 in 2007. As of 2009, the age-adjusted mortality rate for unintentional injury was highest among males (80) when compared to females and local rates were higher than the state. Senior citizens continue to have the highest death rate from unintentional injuries (543.6).

Figure 63. Age-Adjusted Mortality Rates from Unintentional Injuries, Louisville Metro 2000-2009 Death Rate per 100,000 Population 70 58.2 60 56 56

50 39.7 39.4 41.2 39.7 37.5 37.1 40 33.2

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: 2009 Louisville Metro Death Records, Kentucky Department for Public Health

Figure 64. Age Specific Mortality Rates from Unintentional Injury Louisville Metro, 2009

Rate per 100,000 Population 600 543.6 500

400

300

200 156.8 66.1 74.0 100 27.9 42.7 47.9 41.6 53.1 10.6 0 0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ years years years years years years years years years years

Source: 2009 Louisville Metro Death Records, Kentucky Department for Public Health

Figure 65. Age-Adjusted Mortality Rates from Unintentional Injuries by Gender, 2009

Death Rate per 100,000 Population 90 Male 80 80 71 70 Female 60 50 37 40 34 30 20 10 0 Louisville Metro Kentucky

Sources: 2009 Louisville Metro Death Records, Kentucky Department for Public Health; National Center for Health Statistics

MOTOR VEHICLE CRASHE S

In 2009, the Louisville Metro age-adjusted mortality rate from motor vehicle crashes was higher than the national rate and Healthy People 2010 goal of 9.2. As with previous years, Louisville Metro whites exhibited a higher age-adjusted death rate from motor vehicle crashes than blacks. Males exhibited a greater age-adjusted mortality rate from motor vehicle crashes than females. Between 2000 and 2006, Louisville Metro had lower age-adjusted death rates for motor vehicle crashes. However, in 2007 Louisville Metro rates increased, surpassing the national average to 20 per 100,000.

Figure 66. Age-Adjusted Death Rates for Motor Vehicle Crashes 1999-2009 Louisville Metro

Death Rate per Kentucky 100,000 Population 23.7 United States 25 22.5 22.6 22.6 22.2 21.1 20.1 20.5 20 19 20 17 15.7 20 15.3 15.5 15.4 15.3 14.8 15.3 15.1 19 14.0 14.4 14 15 13.3 13 16 12.0 12 11.1 11.8 9.4 10 11.9

0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: 2009 Louisville Metro Death Records; Kentucky Department for Public Health; National Center for Health Statistics

Figure 67. Age-Adjusted Mortality Rates for Motor Vehicle Crashes, 2009 Death Rate per 100,000 Population

30 Healthy People 2010 Goal = 9.2 24.2 24.4 25

20 17 16 16 15 13 11.7 9.8 10.5 10

0 LM Blacks LM Whites LM Male LM Female Louisville KY Male KY Female Kentucky United Metro States Source: 2009 Louisville Metro Death Records; Kentucky Department for Public Health; National Center for Health Statistics

PEDESTRIAN AND BICYCLE CRASHES

For Louisville Metro, the number of bicycle and pedestrian collisions did not substantially change between 2000 and 2010. However, for the past ten years, pedestrian collisions occurred more frequently than bicycle. As of 2010, there were 166 bicycle collisions and 431 pedestrian collisions.

Figure 68. Number of Pedestrian Collisions and Related Number of Deaths, Louisville Metro, 2010 Pedestrian Collisions Pedestrian Deaths Number 500 427 431 411 406 382 396 396 391 400 364 371

300

200

100 10 10 16 15 14 20 13 24 8 19 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year

Source: 2000-2010 Kentucky Uniform Police Traffic Collision Reports

Although there was a decline in the number of bicycle collisions from 2003 to 2004, bicycle collisions have increased since 2001 to 166 in 2010. Bicycle deaths also increased from 1 in 2001 to 3 in 2010.

Figure 69. Number Bicycle Collisions and Related Deaths Louisville Metro, 2010

Number Bicycle Collisions Bicycle Deaths 200 176 168 163 160 160 166 152 158 155 160 133 120

40 1 1 2 1 3 2 1 3 2 3 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year

Source: Kentucky Uniform Police Traffic Collision Reports, 2001-2010

INTENTIONAL INJURIES

What is it?

An intentional injury occurs when there is physical or bodily harm that was purposefully inflicted. This includes injuries as the result of violence or suicide. For purposes of this report, non-fatal intentional injuries are not included.

Why is it important?

Homicide is one of the top-five causes of death in the age groups between 1 and 34 years in the U.S. In 2007, there were 18,361 homicides, with an age-adjusted mortality rate of 6.1.44 Black men have a disproportionately higher rate of homicide in the U.S. Homicide was the fourth leading cause of death for black men in the U.S. and the sixth leading cause of death for Hispanics in 2006.45

Like homicide, suicide is a serious public health issue that has a lasting impact on communities. In 2006, suicide was ranked as the 11th leading cause of death among persons ages 10 years and older, accounting for 33,289 deaths.46 Causes of suicide are complex and determined by multiple factors. They can include mental health issues, substance abuse, alcoholism, a history of abuse or loss. However, protective factors such as clinical care for mental, physical and substance abuse disorders are designed to “buffer” individuals from suicidal thoughts and behavior. These protective factors are considered to be effective prevention.47

What’s Louisville Metro’s status?

HOMICIDE

In 2009, the age-adjusted mortality rate from homicide in Louisville was 11 deaths per 100,000 population. This rate was more than double to the state (5) and nation (5.5) for the same year. It also exceeds the Healthy People 2010 goal of 3 deaths per 100,000 population. Age-adjusted death rates for blacks (37) remained higher than for whites (5) in Louisville Metro.

Figure 70. Age-Adjusted Death Rates for Homicide, 2009 Death Rate per 100,000 Population

40 37 35 Healthy People 2010 30 Goal = 3 25

20 17 15 11 10 6 5 4 5 5 0 LM Blacks LM Whites LM Males LM Females Louisville Kentucky United Metro States Source: 2009 Louisville Metro Death Records, Kentucky Department for Public Health; National Center for Health Statistics

Figure 71. Trends of Age-Adjusted Mortality Rate for Homicide Louisville Metro Death Rate per 100,000 Population 25 19.8 20

15 12 11 9.3 9.8 10 6.3 8.0 9.4 5 6.9 6.8 7.2

0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year Source: Louisville Metro Death Records, Kentucky Department for Public Health

Since 1999, homicide death rates ranged from 6.9 to 11 per 100,000 population, with a sharp rise occurring between 2006 and 2007. Death rates by age from homicide are the highest among age groups of 15 to 24 years and 25 to 34 years. However, homicide rates for the age group 45 to 54 years also increased from the previous year. For the age group 85 years and older, homicide death rates decreased from the previous year. Age-adjusted homicide death rate for males was more than four times that for females.

Figure 72. Trends of Age-Specific Mortality Rates from Homicide Louisville Metro Area Death Rate per 100,000 Population 30

20 2007 2008 15 2009

0 0-4 5–14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Age Groups Source: 2008, 2009 Louisville Metro Death Records, Kentucky Department of Public Health

SUICIDE

The number and rate of suicide deaths in Louisville Metro have fluctuated since 1996 with no consistent trend. Ninety-eight suicide deaths occurred in Louisville Metro in 2009. The age- adjusted mortality rate of 13.9 per 100,000 population was higher than the state rate of 13 and national rate (12). Suicide deaths decreased from the previous year (16 per 100,000). Whites have higher rates for suicide than blacks.

Figure 73. Age-Adjusted Death Rates for Suicide, 2009 Death Rate per 100,000 Population 25 Healthy People 2010 22 Goal = 4.8 20 16 14 15 13 12

10 8 7

0 LM Blacks LM Whites LM Males LM Females Louisville Kentucky United Metro States

Source: 2009 Louisville Metro Death Records, Kentucky Department for Public Health; National Center for Health Statistics

Figure 74. Age-Adjusted Death Rates from Suicide Louisville Metro,1999-2009 Death Rate Per 100,000 Population 18 16.7 16.1 16 14.1 13.9 13.2 12.9 12.8 13.2 14 12.1 12 10.6 10.4 10 8 6 4 2 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Louisville Metro Death Records, Kentucky Department for Public Health

In 2009, the highest rate of suicide was among those aged 65 to 74 years old, followed by those aged 55 to 64 years old. During 2009, the Louisville Metro age-adjusted suicide mortality rate for males was approximately three times higher than females.

Figure 75. Age-Adjusted Death Rates from Suicide by Gender, Louisville Metro, 2009 Death Rate Per 100,000 Population 25 21.5 21.3 20 Male

15 Female

10 7.6 5.2 5

0 Louisville Metro Kentucky

Source: 2009 Louisville Metro Death Records, Kentucky Department of Public Health

Figure 76.

Age-Specific Death Rates from Suicide 2007 Louisville Metro, 2007-2009 Death Rate Per 2008 100,000 Population 2009 35

0 Under 5 5 to 14 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 to 84 85+

Source: 2009 Louisville Metro Death Records, Kentucky Department of Public Health

COMMUNICABLE DISEASES

The incidence (number of new cases reported) of communicable diseases is often used as an important indicator of the status of a community’s health. The table below contains the number of new case reports and the rates per 100,000 population during calendar year 2009 for selected communicable diseases for Louisville Metro, Kentucky, and the United States. It also includes for comparison purposes, the rate for Healthy People 2010 were applicable. Calendar year 2009 data is the most recent year of data available that allows comparisons between local, state, and national case rates.

Table 4. Communicable Disease Rates, 2009 (Rate=incidence per 100,000) Louisville HP Kentucky U.S. Metro 2010 Population Estimates 721,594 4,314,113 307,006,550 (denominator) HIV (Rate) 18.2 9.1 17.4 NRG HIV (Case Count) 131 393 42,959 Primary and Secondary 5.7 2.2 4.6 0.2 Syphilis (Rate) Primary and Secondary 41 92 13,997 Syphilis (Case Count) Gonorrhea (Rate) 259.8 89.6 99.1 19.0 Gonorrhea (Case Count) 1,875 3,827 301,174 Chlamydia (Rate) 561.0 311.4 409.2 NRG Chlamydia (Case Count) 4,048 13,293 1,244,180 Tuberculosis (Rate) 3.5 1.8 3.8 1.0 Tuberculosis (Case 25 77 11,545 Count) Pertussis (Rate) 3.9 5.2 5.5 NRG Pertussis (Case Count) 28 226 16,858 Measles (Rate) 0.0 0 0.05 0.0 Measles (Case Count) 0 0 71 NRG = No Related Goal The HIV case count for 2009 is provisional due to reporting delays and is subject to change

HIV/AIDS

What is it?

Acquired Immunodeficiency Syndrome (AIDS) is the most advanced stage of illness that occurs following infection with the human immunodeficiency virus (HIV). HIV infection progressively destroys a body’s ability to protect itself from infection. A person with HIV infection is diagnosed as having AIDS when their body produces abnormally low numbers of white blood cells. A person with AIDS thus becomes ill with opportunistic infections, develops diseases that affect the central and peripheral nervous system, develops malignancies, or displays a wasting syndrome not usually seen in people without HIV infection.

Why is it important?

An estimated 1.2 million people in the U.S. are living with HIV infection, 20% of whom are unaware of their infection.48 Approximately 50,000 Americans become infected with HIV each year. CDC estimates that over one million people in the U.S. have been diagnosed with AIDS since the epidemic began. Blacks face the most severe burden of HIV of all racial and ethnic groups in the U.S. Despite representing 14% of the population in 2009, blacks accounted for 44% of all new HIV infections in the same year.49

HIV is transmitted from person to person through contact with body fluids, including blood, semen, vaginal secretions, and breast milk. The most common behaviors associated with a risk for infection (modes of exposure) are sexual contact with or sharing needles or syringes used by HIV infected people.50 HIV can also be transmitted from women to their babies during pregnancy, delivery, or through breast-feeding. It cannot be transmitted through sweat, tears, saliva or casual contact.51

There is no cure for HIV/AIDS or vaccine to prevent HIV infection. Antiretroviral medications can prevent the worsening of the disease, but these therapies do not cure the infection and can have severe side effects. Knowing whether one is positive or negative through testing is essential to reducing the spread of HIV. Studies have found that once infected persons are informed of their positive HIV status, they tend to decrease behaviors that transmit the infection to others.

What is Louisville Metro’s status?

The first full year of confidential name-based HIV reporting in Kentucky was 2005. From 2005 to 2007, HIV incidence rates in Louisville Metro were trending upward, but began to fall in 2007 from a high of 22.6 per 100,000 population (171 cases) to 18.2 per 100,000 population (131 cases) in 2009.

Figure 77. HIV Case Rates by Year of Diagnosis Louisville Metro

Rate per 100,000 22.6 25 21.2 21.6 20 19.5 18.2 15

0 2005 2006 2007 2008 2009

Year Source: Kentucky Department for Public Health

Of the total number of new HIV cases diagnosed in 2009, men who have sex with men (MSM) remains the predominant mode of exposure (37.4%), followed by injection drug use (IDU) at 6.1%. Some modes of exposure were identified by less than 5 individuals during 2009. All of those low frequency groups combined account for 4.6% of the exposures. No exposure mode was determined/identified for approximately 52% of the new HIV cases.

Figure 78. HIV Mode of Exposure Louisville Metro, 2009 For modes with 5 or more reports

MSM

37.4% IDU

Groups with <5 reports 51.9% Undetermined

6.1% 4.6%

Source: Kentucky Department for Public Health

Following national trends, blacks have a higher rate of reported cases of HIV than whites in Louisville Metro. The rate of new HIV cases reported in 2009 for Louisville Metro white males was higher than the national rate for white males. Although lower than the national rates, rates for Louisville Metro blacks were higher than those for Louisville Metro whites.

Figure 79. HIV Case Rates by Race, 2009

Rate per 100,000 60 49.3 50 43.7 40 White

30 Black

20 11.2 10 5.3

0 Louisville Metro USA Source: Kentucky Department for Public Health

PRIMARY AND SECONDARY SYPHILIS

What is it?

Syphilis is a sexually transmitted disease caused by the Treponem.pallidum bacterium. The organism is transmitted from an infected individual when one has direct contact with an infected person’s sores.52 The sores can be found on the external genitals, the vagina, anus, rectum, mouth, or lips. Unprotected anal, oral, or vaginal sex with an infected individual is a mode of exposure for syphilis. In addition, pregnant infected women can transmit the disease to their babies. The number of primary and secondary syphilis cases is an important community health indicator because it represents individuals recently infected with syphilis who are capable of transmitting the disease to uninfected people.

Why is it important?

Syphilis is a sexually transmitted disease that has resulted in devastating epidemics. If the disease is untreated, the signs and symptoms that can develop as a result of a late stage of syphilis infection include difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, dementia, and even death.

According to the CDC, the most effective prevention against syphilis and other sexually transmitted diseases is to abstain from sexual contact or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected. Avoiding alcohol and drug use which can lead to risky behavior can also prevent transmission. Although the use of condoms during sex is also a preventive method, the infected area or site of potential exposure must also be covered.

What is Louisville Metro’s status?

The number of new cases of primary and secondary syphilis in Louisville Metro increased substantially from 27 cases (3.8 per 100,000 population) in 2008 to 41 (5.7 per 100,000 population) in 2009. Men who have sex with men (MSM) and in particular HIV infected MSM are the most frequent exposure risks that have been documented in syphilis cases seen in Louisville Metro in 2009.

Nationally during 2009 the rates of reported cases for black males and females were higher than the rates seen in white males and females. This pattern is mirrored in Louisville Metro, however the rates for white males were higher than national rates while local black males and females had rates less than this demographic group nationally.

Figure 80. Primary and Secondary Syphilis Case Rates by Year of Diagnosis

Rate per 100,000

7.0 6.0 5.7 5.0 5.6 3.7 3.8 4.0 5.0 3.0 2.0 1.0 0.0 2005 2006 2007 2008 2009 Year

Source: Kentucky Department for Public Health

Figure 81. Primary and Secondary Syphilis Case Rates by Race and Gender, 2009

White Rate per 100,000 Males 35 31.3 White 30 Females 25 22.4 Black 20 Males 15 Black 8.7 8.2 10 Females 3.9 5 1.3 0.0 0.4 0 Louisville Metro USA

Source: Kentucky Department for Public Health

CHLAMYDIA

What is it?

Chlamydial infections are the most common reportable disease in the United States. These infections are caused by the Chlamydia.trachomatis bacterium. Approximately 50% of infections in men and 75% in women did not involve obvious symptoms in the early stages. Individuals in the 15 to 24 year age group show the highest rates of infection.

Why is it important?

In women, chlamydial infections may result in pelvic inflammatory disease which can lead to infertility, ectopic pregnancy, and chronic pelvic pain. As with other inflammatory, sexually transmitted diseases, chlamydial infections can increase the transmission of HIV infection. In addition, pregnant women infected with chlamydia can pass the infection to their infants during delivery, causing eye infections and pneumonia.53 Chlamydia can be easily can be easily treated and cured with antibiotics.

What is Louisville Metro’s status?

The number of new chlamydial infections per 100,000 population in Louisville Metro increased in 2009 (561.0 per 100,000 population) compared to 2008 (540.4 per 100,000 population). The rate of new chlamydial infections seen in Louisville Metro for 2009 (561.0 per 100,000) was higher than the rate seen in Kentucky (approximately 311 per 100,000) and the national rate (approximately 409 per 100,000).

Figure 82. Chlamydia Case Rates by Year of Diagnosis, Louisville Metro

Rate per 100,000 540.4 600 561.0 500 356.9 352.7 367.7 400 300 200 100 0 2005 2006 2007 2008 2009 Year Source: Kentucky Department for Public Health

When examining reported cases of chlamydia, blacks have higher rates than whites and females show higher rates than males at both the local and national level. Local rates for white and black males were similar to rates seen nationally, while local rates for white and black women were lower than those seen in the corresponding national categories.

Figure 83. Chlamydia Case Rates by Race and Gender, 2009 Rate per 100,000 2500 White Males 2095.5 2000 White Females 1461.2 1500 Black 970 959.2 Males 1000

Black 500 209.2 270.2 Females 83.2 84 0 Louisville Metro USA

Source: Kentucky Department for Public Health

GONORRHEA

What is it?

Gonorrhea is a sexually transmitted disease caused by the Neisseria.gonorrhoeae bacterium. Neisseria.gonorrhoeae can live and grow in parts of a male’s or female’s reproductive tract, anus, rectum, mouth, throat or eyes.

Why is it important?

Like chlamydia, gonorrhea is the most commonly reported infectious disease in the U.S. Gonorrhea is a cause of pelvic inflammatory disease in women, a major cause of infertility, ectopic pregnancy, and chronic pelvic pain. It can also be transmitted from mother to child during pregnancy. In men, gonorrhea infections can produce painful testicular infections that can lead to infertility. Gonorrhea can also facilitate the transmission of HIV infection for both men and women. It occasionally spreads to a person’s blood or joints and becomes a life-threatening infection.

CDC urges STD screening particularly among young people aged 15-24 years.54 Screening has been identified as one of the most effective, but underutilized, methods to identify and treat those who are infected and to help prevent the further spread of STDs such as gonorrhea.

What is Louisville Metro’s status?

Nationally, the reported rate for gonorrhea in 2009 declined compared to the previous year, 112 new cases per 100,000 population in 2008 to 99.1 per 100,000 in 2009. The number of new gonorrhea cases per 100,000 population in Louisville Metro increased steadily from 2005 to 2008. In 2009, the local rate began to mirror the trend seen at the national level by recording a 9% decrease in rate.

The rate of new gonorrhea cases seen in 2009 (259.8 per 100,000) in Louisville Metro was almost three times greater than the rate seen in Kentucky and more than thirteen times greater than the national Healthy People 2010 goal of 19 per 100,000 population. The overall rate for gonorrhea in 2009 is more than two times higher for Louisville Metro compared to the national rate.

Figure 84. Gonorrhea Case Rates by Year Louisville Metro

Rate per 100,000

350 286.2 300 212.3 250 198.4 259.8 200 232.9 150 100 50 0 2005 2006 2007 2008 2009 Year

Source: Kentucky Department for Public Health

The distribution of gonorrhea cases during 2009 by race and gender in Louisville Metro follows the pattern seen nationally, with rates much higher in blacks than in whites. Gonorrhea incidence rates for all local race/gender combinations are higher locally than they are for the corresponding groups nationally.

Figure 85. Gonorrhea Case Rates by Race and Rate per 100,000 Gender, 2009 Rate per 100,000 White Males 1000 915.8 900 White 800 692.3 Females 700 555.2 557.5 600 Black 500 Males 400 300 Black Females 200 61.5 100 30.8 21.5 32.8 0 Louisville Metro USA Source: Kentucky Department for Public Health

TUBERCULOSIS

What is it?

Tuberculosis (TB) is a disease caused by the Mycobacterium.tuberculosis bacterium. The bacteria can infect any part of the body, but they are commonly found in the lungs. TB can be spread through the air from one person to another. The bacteria are put into the air when a person with TB disease of the lungs or throat coughs or sneezes. People who are physically close to the infected individual may breathe in these bacteria and become infected.

Although no safe exposure time to M.tuberculosis has been established, it is clear that a number of factors influence the probability that a person will develop TB after an exposure to the bacterium. Those factors include the extent of the disease in the TB case, the duration of contact and the proximity of contact between the TB case and exposed individuals, and the contact’s general health and immune status.

Why is it important?

TB was once the leading cause of death in the United States. Although TB case rates declined after World War II, they increased, nationally, between 1985 and 1992. National TB case rates have been declining since then, but there were still nearly 13,000 cases in the United States in 2008.

What is Louisville Metro’s status?

The rate of new cases of TB in Louisville Metro has fluctuated over the past five years and in 2009 was below the average of case counts for the past 5 calendar years. The Louisville Metro case rate (3.5 per 100,000) was higher than the rate seen for Kentucky (1.8 per 100,000) and slightly less than the national rate (3.8 per 100,000). The rate of new TB cases in Louisville Metro for 2009 was 3.5 times higher than the goal of one (1) new case per 100,000 persons set by the Healthy Kentuckians 2010 and Healthy People 2010 reports.

Figure 86. Tuberculosis Case Rates by Year of Diagnosis, Louisville Metro

Rate per 100,000

4.7 5 4.4 3.9 4 3.5 3.0 3

1 2005 2006 2007 2008 2009 Year

Source: Kentucky Department for Public Health

Case rates in 2009 for Louisville Metro were higher for white males, and white females compared to national rates. Although blacks have more cases of TB than would be predicted based on their population counts at a national and local level, the disparity between blacks and whites is smaller in Louisville Metro than it is in the country as a whole and TB rates among black males and females in Louisville Metro are less than those seen nationally.

Figure 87. TB Case Rates by Race and Gender, 2009 Rate per 100,000 White 18 Males 16 White 14 Females 12 9.8 10 9.0 Black Males 8 5.7 6 Black 3.9 3.2 Females 4 2.6 1.2 2 0.6 0 Louisville Metro USA Source: Kentucky Department for Public Health

MEASLES

What is it?

Measles is a highly contagious respiratory disease caused by a virus. Symptoms include rash, high fever, runny nose, and eyes.

Why is it important?

Before 1963, there were an average of 3 to 4 million cases and 450 deaths caused by measles in the United States each year. In addition to death, other complications following measles infection include encephalitis (inflammation of the brain), which can lead to deafness; mental retardation; or miscarriage, premature birth, and birth of low weight babies in pregnant women who are infected.

What is Louisville Metro’s status?

Although there were 71 cases of measles in the United States (51 indigenous and 20 imported), no new cases were reported in Louisville Metro or Kentucky in 2009. In the past five years Louisville Metro has not recorded any new cases of measles. The last local measles reports were two cases in 1999. A nearly universal childhood vaccination program using a very effective vaccine coupled with effective reporting and surveillance programs have contributed to these very low new case rates locally and nationally.

PERTUSSIS

What is it?

Pertussis, commonly known as whooping cough, is a highly contagious respiratory infection caused by the Bordetella.pertussis bacterium. Symptoms often last for many weeks and in young children may include severe bouts of coughing with a “whooping” sound as the child tries to inhale between coughs. The child may vomit after a coughing spasm. Symptoms in adolescents and adults may not be as severe as they are in young children.55

Why is it important?

Complications resulting from the initial infection can occur (particularly in young children) and may be life threatening. Immunization can prevent, or at least reduce the severity of, the infection. However, children who are too young to be vaccinated or who have started the vaccination series, but have not had the time to develop immunity are at risk for the infection.

Immunity to B.pertussis wanes over time. A Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine has been licensed for use in adolescents and adults. Since this population has, historically, been a continuing reservoir of infection in the community, the use of Tdap in this population could reduce pertussis incidence substantially.

What is Louisville Metro’s status?

The rate of new pertussis cases per 100,000 population in Louisville Metro has fluctuated over the past five years but, like national and state trends, has increased in the last year. In 2009 the local rate increased from the 2008 rate of 3.6 cases per 100,000 to 3.9 per 100,000 population.

Figure 88. Pertussis Case Rates by Year of Diagnosis Louisville Metro Rate per 100,000

12 10.7 10 8

6 3.6 3.9 1.8 4 1.9 2 0 2005 2006 2007 2008 2009

Year

Source: Kentucky Department for Public Health

The distribution of the 28 cases of pertussis reported in Louisville Metro during 2009 approximated national trends. In Louisville and nationally the largest percentage of cases fell in the 5 to 14 year age group with the second highest percentage in the less than 1 year age group. No local cases appeared in Louisville Metro residents older than 64 year age group and a smaller than expected percentage appeared in the other groups, compared to national percentages.

Figure 89. Percentage of Total Pertussis Cases by Age Group Louisville Metro and USA, 2009

Percent of Total Cases

45% 42.9% Louisville 39.3% 38.8% Metro 40% USA 35% 30% 25% 20% 18.3% 15% 12.5% 10.4% 10% 7.1% 8.5% 8.3% 3.6% 5% 3.6% 3.6% 2.0% 0.0% 0% <1 year 1 to 4 5 to 14 15 to 24 25 to 39 40 to 64 >64 years years years years years years

Age Group

Source: Kentucky Department for Public Health

Louisville Metro is fortunate to have a children’s hospital in the community that has been a pioneer in the screening and diagnosis of pertussis cases in their patient population. The consistent surveillance and reporting from that hospital could help to explain the observation that at a local level 89.3% of cases are reported in children less than 1 year of age through 14 years of age.

Nationally, pertussis rates are higher in Whites than in blacks. Historically, a similar pattern has been seen in Louisville Metro, but in 2009 blacks had a higher case rate than Whites.

Figure 90. Pertussis Case Rates by Race, 2009

Rate per 100,000 9.0 8.0 7.6 7.0 White 6.0 Black 5.0 4.64 4.0 3.0 1.9 1.85 2.0 1.0 0.0 Louisville Metro USA Source: Kentucky Department for Public Health

INFLUENZA AND THE 2009/2010 PANDEMIC

What is it?

Influenza is a contagious respiratory disease caused by influenza viruses. Symptoms can include fever, cough, sore throat, runny or stuffy nose, muscle or body aches, headaches, fatigue, and, more commonly in children than adults, vomiting and diarrhea.

Certain groups of people are at greater risk for serious complications if they get the flu. These groups typically include older people, young children, pregnant women and people with certain health conditions (such as asthma, diabetes, or heart disease).

Why is it important?

During 2009-2010, a new and very different flu virus (called 2009 H1N1) spread worldwide causing the first flu pandemic in more than 40 years. CDC estimated that the 2009 H1N1 pandemic resulted in more than 12,000 flu-related deaths in the U.S. In contrast to deaths attributed to seasonal flu, nearly 90 percent of the 2009 H1N1 associated deaths occurred among people younger than 65 years of age.56

The illness is so mild for many people with influenza that they use over the counter medications to treat symptoms and they are never seen by a health care professional. Among those people who have influenza with symptoms severe enough to seek treatment from a medical professional, many are diagnosed based on clinical signs and symptoms and are never tested to confirm the diagnosis. Some of the people who are diagnosed with “Flu-like” of “Influenza like” illness may be tested using rapid influenza test kits that don’t meet the requirements demanded by the case definition for

93 influenza. The small subset of patients seen by health care providers with a diagnosis confirmed by an approved laboratory test for influenza are the only individuals counted as confirmed influenza cases each year and they represent the tip of the iceberg of disease actually present in the community.

What is Louisville Metro’s status?

The total disease burden cannot be determined by a count of culture confirmed cases, however by tracking the number of cases we can determine the start, the high point(s), and end of the influenza season in our community. A typical influenza season lasts a month or two. The count of confirmed influenza cases for 2009 and the first half of 2010 is unusual in that there were culture confirmed reports of Influenza and/or 2009 H1N1 for 13 consecutive months. The H1N1 season began in May 2009 in Louisville. Peak report months were September, October and November, 2009. Influenza reports and illness continued in the county until June, 2010.

Figure 91. Confirmed Influenza and 2009 H1N1 Isolates Jefferson County - 5/2009 to 6/2010 300

250 Influenza Isolates 200 2009 H1N1 150

100

Confirmed Case Case ConfirmedCount 50

Month/Year

Source: Kentucky Department for Public Health

GLOSSARY OF TERMS

Age-adjusted death rate: The ratio of total number of expected deaths in a standard population by total standard population (based on 2000 U.S standard population) belonging to the same specific age category and multiply this result by 100,000.

Birth rate: The number of births per 1,000 resident population.

Cause specific hospitalization rate: The total number of adult and pediatric hospital separations (discharges, transfers and deaths) due to a selected cause per 100,000 population during a calendar year.

Crude Hospitalization Rate: is the total number of adult and pediatric hospital separations (discharges, transfers and deaths) during a calendar year per total population (per 100,000).

Healthy People: Healthy People provide science-based, 10-year national objectives for improving the health of all Americans. Healthy People serves as the foundation for prevention efforts across the U.S. Department of Health and Human Services (HHS).

Incidence: The number of newly diagnosed cases during a specific time period.

Infant mortality rate: The number of newborns dying in a calendar year of age divided by the number of live births registered during the same year.

In-patient hospitalizations: Number of adult and pediatric hospital separations (discharges, transfers and deaths), excluding newborn days of care, rendered during the calendar year.

Low birth weight: Infants who weigh less than 2500 grams (or 5.8 pounds) at birth.

Median household income: level of income at which half of all households are above and half are below.

Morbidity: A diseased condition or state in a person or population.

Percentage: A proportion stated in terms of one-hundredths that is calculated by multiplying a fraction by 100.

Prenatal care: Health care and other services available to pregnant women as a fetus develops within her uterus.

Very low birth weight: Infants classified as those weighing less than 1500 grams (or 3.5 pounds).

ENDNOTES

1 Louisville/Jefferson County Merger . (n.d.). Retrieved Nov 15, 2011, from Louisvilleky.gov: http://www.louisvilleky.gov/YourGovernment/Merger.htm

2 Hyon, B. R. (2003, Oct). Language Use and English Speaking Ability. Retrieved Nov 16, 2011, from U.S.Census Bureau: http://www.census.gov/prod/2003pubs/c2kbr-29.pdf

3 THE 2009 HHS POVERTY GUIDELINES. (2009, Jan 23). Retrieved 2010, from U.S.Department of Health and Family Services: http://aspe.hhs.gov/poverty/09poverty.shtml

4 Eliminate Disparities in Infant Mortality. (n.d.). Retrieved Nov 2011, from Centers for Diseases Control and Prevention: http://www.cdc.gov/omhd/AMH/factsheets/infant.htm#Risk

5 Birth Defects: Leading Cause of Infant Death. (n.d.). Retrieved Oct 2011, from Centers for Disease Control and Prevention: http://www.cdc.gov/Features/dsInfantDeaths/

6 Russo, C. E. (2007, Jan). Hospitalizations for Birth Defects, 2004. Retrieved 2010, from Health Care Cost and Utilization Project: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb24.pdf

7 Birth Defects: Leading Cause of Infant Death. (n.d.). Retrieved Oct 2011, from Centers for Disease Control and Prevention: http://www.cdc.gov/Features/dsInfantDeaths/

8 Benbow, N. (2007). Big citites Health Inventory, The Health of Urban USA. Washington, DC: National Association of County and City Health officials.

9 Health, U. D. (n.d.). Prenatal Care factsheet. Retrieved 2011, from Womens Health.gov: http://www.womenshealth.gov/publications/our-publications/fact-sheet/prenatal-care.cfm#d

10 Teen Pregnancy:(2009). Retrieved Nov 2011, from Centers for Disease Control and Prevention: http://www.cdc.gov/TeenPregnancy/AboutTeenPreg.htm

11 Lead. (2010). Retrieved Nov 2011, from Centers for Disease Control and Prevention: http://www.cdc.gov/nceh/lead/

12 Children and Lead Health Effects. (n.d.). Retrieved 2010, from Coalition to end childhood lead poisoning: http://www.leadsafe.org/content/kids_and_lead/index.cfm?pageId=31

13 What is Cardiovascular Disease? . (2011). Retrieved Nov 2011, from American Heart Association: http://www.heart.org/HEARTORG/Caregiver/Resources/WhatisCardiovascularDisease/What-is-Cardiovascular- Disease_UCM_301852_Article.jsp

14Blood Vessels in Your Heart. (n.d.). Retrieved Nov 2011, from Boston Scientific: http://www.bostonscientific.com/templatedata/imports/HTML/CRM/heart/heart_vessels.html

15 Heart Disease: Heart Disease Facts. (n.d.). Retrieved 2011, from Centers for Disease Control and Prevention: http://www.cdc.gov/heartdisease/facts.htm

16 Understand Your Risk of Heart Attack. (2011, Nov 22). Retrieved 2011, from American Heart Association: http://www.heart.org/HEARTORG/Conditions/HeartAttack/UnderstandYourRiskofHeartAttack/Understand-Your- Risk-of-Heart-Attack_UCM_002040_Article.jsp#

17 What is Cancer: Defining Cancer. (2011, July 29). Retrieved 2011, from National Cancer Institute: http://www.cancer.gov/cancertopics/cancerlibrary/what-is-cancer

18 Estimated New Cancer Cases and Deaths by Sex for All Sites, US, 2011*. (2011). Retrieved Nov 2011, from American Cancer Society: http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-029817.pdf

19 Lung Cancer. Retrieved 2011, from Centers for Disease Control and Prevention: http://www.cdc.gov/cancer/lung/

20 Lung Cancer:Risk Factors. Retrieved 2011, from Centers for Disease Cotrol and Prevention: http://www.cdc.gov/cancer/lung/basic_info/risk_factors.htm

21 Lung Cancer:Risk Factors. Retrieved 2011, from Centers for Disease Cotrol and Prevention: http://www.cdc.gov/cancer/lung/basic_info/risk_factors.htm

22 Breast Cancer: What are the key statistics about breast cancer? (2011, Nov 18). Retrieved 2011, from American Cancer Society: http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-key- statistics

23 Estimated New Cancer Cases and Deaths by Sex for All Sites, US, 2011*. (2011). Retrieved Nov 2011, from American Cancer Society: http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-029817.pdf

24 Prostate Cancer. (n.d.). Retrieved 2011, from American Cancer Society: http://www.cancer.org/Cancer/ProstateCancer/index

25 Prostate Cancer. (n.d.). Retrieved 2011, from Centers for Disease Control and Prevention: http://www.cdc.gov/Features/ProstateCancer/

26 Chronic Obstructive Pulmonary Disease (COPD). (n.d.). Retrieved 2011, from Centers for Disease Control and Prevention: http://www.cdc.gov/Features/COPD/

27Stroke, Cerebrovascular accident. (n.d.). Retrieved 2011, from World Health Organization: http://www.who.int/topics/cerebrovascular_accident/en/

28 Features: Stroke. (n.d.). Retrieved 2011, from Centers for Disease Control and Prevention: http://www.cdc.gov/Features/Stroke/

29 Diabetes Basics. (2011, Jan 26). Retrieved 2011, from american Dia betes Association: http://www.diabetes.org/diabetes-basics/diabetes-statistics/

30 Diabetes Basics. (2011, Jan 26). Retrieved Nov 2011, from American Diabetes Association: http://www.diabetes.org/diabetes-basics/diabetes-statistics/

31 Asthma in the US. (2011, May). Retrieved 2011, from Centers for Disease Control and Prevention: http://www.cdc.gov/vitalsigns/Asthma/

32Healthy Youth: Asthma. (n.d.). Retrieved 2011, from National Center for Chronic Disease Prevention and Health Promotion: Centers for Disease Control and Prevention: http://www.cdc.gov/HealthyYouth/asthma/

33 More Americans Living with Asthma Every Year . (n.d.). Retrieved 2011, from Centers for Disease Control and Prevention: http://www.cdc.gov/Features/VitalSigns/Asthma/

34More Americans Living with Asthma Every Year . (2011, April 04). Retrieved 2011 from Centers for Disease Control and Prevention: http://www.cdc.gov/Features/VitalSigns/Asthma/

35 The Health Effects of Overweight and Obesity. (n.d.). Retrieved 2010, from Centers for Disease Control and Prevention: http://www.cdc.gov/healthyweight/effects/index.html

36 Obesity and overweight. (2011, March). Retrieved 2011, from Whorld Health Organization: http://www.who.int/mediacentre/factsheets/fs311/en/

37 Physical Activity and Blood Pressure. (n.d.). Retrieved 2010 2011, from American Heart Association: http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/P hysical-Activity-and-Blood-Pressure_UCM_301882_Article.jsp

38 The Nutrition Source: Vegetables and Fruits. (n.d.). Retrieved 2011, from Harvard School of Public Health: http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/vegetables-and-fruits/index.html

39 Smoking and Tobacco Use: Health Effects of Cigarette Smoking. (n.d.). Retrieved 2010, from Centers for Disease Control and Prevention: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/#children

40 What is Mental Health? (2007, Sep 03). Retrieved 2010, from World Health Organization: http://www.who.int/features/qa/62/en/index.html

41 Mental Illness and the Family: Recognizing Warning Signs and How to Cope. (n.d.). Retrieved 2011, from Mental Health America: http://www.nmha.org/go/information/get-info/mi-and-the-family/recognizing-warning- signs-and-how-to-cope

42 Mental Health: Mental Health Basics. (n.d.). Retrieved Nov 2011, from Centers for Disease Control and Prevention: http://www.cdc.gov/mentalhealth/basics.htm

43 Mental Health: Depression. (n.d.). Retrieved Nov 2011, from Centers for Disease Control and Prevention: http://www.cdc.gov/mentalhealth/basics/mental-illness/depression.htm

44 Assault or Homicide. (n.d.). Retrieved 2011, from Centers for Disease Control and Prevention: http://www.cdc.gov/nchs/fastats/homicide.htm

45 Men’s Health: Leading Causes of Death for Men, 2006. Retrieved Nov 2011, from http://www.cdc.gov/men/lcod/index.htm

46 Injury center: Suicide Prevention. (n.d.). Retrieved 2011, from Centers for Disease Control and Prevention: http://www.cdc.gov/ViolencePrevention/suicide/

47 Suicide: Prevention Strategies. (n.d.). Retrieved 2011, from Centers for Disease Control and Prevention: http://www.cdc.gov/ViolencePrevention/suicide/prevention.html

48 HIV in the United States. (n.d.). Retrieved 2011, from Centers for Disease Control and Prevention: http://www.cdc.gov/hiv/resources/factsheets/us.htm

49 HIV among African Americans*. (n.d.). Retrieved 2011, from Centers for Disease Control and Prevention: http://www.cdc.gov/hiv/topics/aa/index.htm

50 Sexual Risk Factors. (n.d.). Retrieved 2010, from AIDS.gov: http://www.aids.gov/hiv-aids- basics/prevention/reduce-your-risk/sexual-risk-factors/

51 Basic Information about HIV and AIDS . (n.d.). Retrieved 2011, from Department of Health and Human Services, Centers for Disease Control and Prevention: http://www.cdc.gov/hiv/topics/basic/#spread

52 Sexually Transmitted Diseases (STDs), Syphilis - CDC Fact Sheet. (n.d.). Retrieved 2010, from Centers for Diseases Control and Prevention: http://www.cdc.gov/std/syphilis/STDFact-Syphilis.htm

53 Sexually Transmitted Diseases (STDs), STDs & Pregnancy - CDC Fact Sheet. (n.d.). Retrieved 2010, from Centers for Disease Control and Prevention: http://www.cdc.gov/std/pregnancy/STDFact-Pregnancy.htm

54 STDs are a major public health issue:. (2011, April 20). Retrieved 2011, from Centers for Disease Control and Prevention: http://www.cdc.gov/Features/STDAwareness/

55 Pertussis (Whooping Cough): Signs & Symptoms. (n.d.). Retrieved 2010, from Centers for Disease Control and Prevention: http://www.cdc.gov/pertussis/about/signs-symptoms.html

56 H1N1 Flu: Updated CDC Estimates of 2009 H1N1 Influenza Cases, Hospitalizations and Deaths in the United States. (2009, April 10). Retrieved 2010, from Centers for Disease Control and Prevention: http://www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm

APPENDIX

ICD-10 CODES FOR MORTALITY DATA Cause of Death ICD-10 Code All Cancer C00-C97 All Causes A00-Y89 Alzheimer’s Disease G30 Asthma J45-J46 Certain Conditions Originating in the Perinatal Period P00-P96 Chronic Liver Disease and Cirrhosis K70, K73-K74 Chronic Lower Respiratory Diseases J40-J47 Congenital Malformations, Deformations, and Q00-Q99 Chromosomal Abnormalities Coronary Heart Disease I11, I20-I25 Diabetes E10-E14 Diseases of Heart I01-I09, I11, I13, I20-I51 Disorders Related to Short Gestation and Low P07 Birth Weight, Not Elsewhere Classified Essential (primary) Hypertension and Hypertensive I10, I12 Renal Disease Female Breast Cancer C50 Homicide X85-Y09, Y87.1 Human Immunodeficiency Virus (HIV) Disease B20-B24 Influenza & Pneumonia J10-J18 Lung Cancer C33-C34 Motor Vehicle Crash V02-V04, V09.0, V09.2, V12-V14, V19.O-V19.2, V19.4-V19.6, V20-V79, V80.3-V80.5, V81.0- V81.1, V82.0-V82.1, V83-V86, V87.0-V87.8, V88.0-V88.8, V89.0, V89.2 Newborn Affected by Maternal Complication of P01 Pregnancy Prostate Cancer C61 Respiratory Distress of Newborn P22 Stroke I60-I69 Sudden Infant Death Syndrome (SIDS) R95 Suicide X60-X84, Y87.0 Unintentional Injury V01-X59, Y85-Y86

100

ICD-10 CODES FOR INJURY MORTALITY DATA

Mechanism All Injury Unintentional Suicide Homicide All Injury V01-Y36, Y85-Y87, Y89 V01-X59, Y85-Y86 X60-X84, X85-Y09, Y87.0 Y87.1

Cut/Pierce W25-W29, W45, X78, X99, W25-W29, W45 X78 X99 Y28, Y35.4

Drowning V90-V90.9, W65-W74, X71, V90-V90.9, W65-W74 X71 X92 X92, Y21

Fall W00-W19, X80, Y01, Y30 WOO-W19 X80 Y01

Fire/Hot object or X00-X19, X76-77, X97-X98, X00-X19 X76-77 X97-X98 substance Y26-Y27, Y35.0

Firearm W32-W34, W72-74, X93-X95, W32-W34 X72-74 X93-X95 Y22-Y27, Y36.3

Machinery W24, 230-W31 W24, W30-W31

All transport V01-V99, X82, Y03, Y32, V01-V99 X82 Y03 Y36.1

Motor Vehicle V02-V04, V09.0, V09.2, V12- V02-V04, V09.0, V09.2, X82 Y03 Crash V14, V19.0-V19.2, V19.4- V12-V14, V19.0-V19.2, V19.6, V20-V79, V80.3-V80.5, V19.4-V19.6, V20-V79, V81.0-V81.1, V82.0-V82.1, V80.3-V80.5, V81.0- V83-V86, V87.0-V87.8, V88.0- V81.1,V82.0-V82.1, V83- V88.8, V89.0, V89.2 V86,VV87.0-V87.8, V88.0- V88.8, V89.0, V89.2 All other transport- V01, V05-V06, V09.1, V09.3, V01, V05-V06, V09.1, X82 Y03 related V09.9, V10, V11, V15-V18, V09.3, V09.9, V10, V11, V19.3, V19.8, V19.9, V80.0- V15-V18, V19.3, V19.8, V80.2, V80.6-V80.9, V81.2- V19.9, V80.0-V80.2, V81.9, V82.2-V82.9, V87.9, V80.6-V80.9, V81.2-V81.9, V88.9, V89.1, V89.3, V89.9, V82.2-V82.9, V87.9, V90-V99, X82, Y03, Y32, V88.9, V89.1, V89.3, Y36.1 V89.9, V90-V99 Natural/environme W42, S45, S53-S64 W42, W43, S53-S64 ntal Overexertion X50 X50 Poisoning X40-X49, X60-X69, X85=X90, X40-X49 X50-X69 X85-X90 Y10-Y19, Y35.2 Struck by or W20-W22, W50-W52, X79, W20-W22, W50-W52 X79 YOO, Y04 against Y00, Y04, Y29, Y35.3 Suffocation W75-W84, X70, X91, Y20 W75-W84 X70 X91

101

ICD-9 CODES FOR IN-PATIENT HOSPITALIZATION DATA

Cause ICD-9 Code

Acquired Immunodeficiency Syndrome (AIDS) 042-044

Alcohol induced morbidity 291,303,305.0,357.5,425.5,535.5,571.0- 571.3,572.8,7903,E860 All Cancer 140-208

All Causes 001-E999

Asthma 493

Breast Cancer 174

Coronary Heart Disease 402, 41-414, 429.2

Chronic Obstructive Pulmonary Disease 490-496

COPD 490-496

Diabetes 250

Diseases of the Heart 390-398, 402, 404-429

Drug induced morbidity 292,304,305.2-305.9,E850-E858,E950.0- E950.5,E962.0,E980.0-E980.5

Heart Disease 391-392.0,393-398,402,404,410-416,420-429

Homicide /Assault E960-E969

Lung Cancer (bronchitis and lung) 162.2-162.9

Mental Disorders 290-319

Motor Vehicle Crashes E810-E825

Neuroses, Personality Disorders and Other Nonpsychotic Mental Disorders 300-316

Perinatal conditions 760-779

Prostate Cancer 185

Psychoses 290-299

Stroke 430-438

Suicide/Self-Inflicted Injury E950-E959

Unintentional Injury E800-E949

102

Appendix B: 2012 LMPHW 2012 Community Health Needs Assessment Survey Results

2012 Community Health Needs Assessment Survey Results

GENERAL PUBLIC SURVEY

Percentage Respondents by Gender

7, 0% 1, 3%

356, 20% Male Male 11, 27% Female Female 1463, 80% Other/Transgender Other/Transgender 28, 70%

Health Department Percentage Respondents by Race and Ethnicity

5, 0% 19, 1% 32, 2% 20, 1% 1, 0% 14, 1% White

282, 15% Black or African American

Asian Yes Native Hawaiian/Other Pacific Islander No 1472, 81% American Indian or Alaska 1792, Native 99% Other

• 99% of the respondents speak English at home

Health Department Percentage Respondents by Race and Ethnicity

1, 2% 0, 0% 1, 2% 0, 0% 0, 0% 0, 0% White

Black or African American

Asian Yes 18, 43% 23, 55% Native Hawaiian/Other Pacific Islander 40, 98% No American Indian or Alaska Native Other

• 96% of the respondents speak English at home

Health Department Percentage Respondents by Age Group

96, 5% 52, 3%

3, 4, 9% 18-24 years 7% 18-24 years

331, 18% 25-34 years 7, 16% 25-34 years 439, 24% 8, 18% 35-44 years 35-44 years

397, 22% 45-54 years 7, 16% 45-54 years 55-64 years 55-64 years 506, 28% 15, 34% More than 65 years More than 65 years

Health Department Percentage Respondents Reported Seeing a Primary Care Provider in the Past 12 Months

5, 11% 299, 16%

Yes Yes No No

1523, 39, 89% 84%

Health Department Percentage Respondents Used the Emergency Room in the Past 12 Months for Self or Another Adult in Their Household

2, 0% 0, 0%

1 to 2 times 8, 18% 1 to 2 times 2, 5% 512, 28% 3 to 5 times 3 to 5 times 1, 6 or more times 2% 6 or more times 1245, 69% 51, None None 3% 33, 75% 7, I don’t know I don’t know 0%

Health Department Percentage Respondents Who Used Emergency Room in the Past 12 Months for a Child Under Their Care?

0, 0% 1, 2% 26, 1% 3, 3, 0% 215, 12% 1, 0% 7%

431, 24% 1 to 2 times 1 to 2 times 3 to 5 times 19, 43% 3 to 5 times 6 or more times 6 or more times None 21, 48% None I don’t know I don’t know 1144, 63% Not applicable Not applicable

0, 0%

Health Department Percentage Respondents Who Had to Use the Emergency Room by Primary Reason of Visit

53, 3%

7, 17% Non-emergency Non-emergency 536, 29% issue 13, 32% issue Urgent issue Urgent issue 692, 38% Emergency Emergency 13, 32% Not applicable Not applicable 540, 30% 8, 19%

Health Department Urgent or Immediate Care 46, 3% Center Clinic in a Grocery Store or 31, 2% Drug Store 8, 0% 250, 14% Hospital Emergency Room Percentage 8, 0% Over the Counter 25, Remedy/Pharmacist Respondents 1% Folk Remedy 113, 6% Helpline 981, 54% Using Alternative 170, 9% Health Department See a Chiropractor or Alternative Source of Care Resources When 191, 11% Rely Upon Family Member They Can’t See a Nothing

0, 0% 0, 0% Urgent or Immediate Care Regular Center 2, 4% 0, 0% 3, 7% Clinic in a Grocery Store or Drug Store 2, 4% HealthCare Hospital Emergency Room Over the Counter Remedy/Pharmacist Provider Folk Remedy 7, 16% Helpline 28, 62% Health Department

2, 5% See a Chiropractor or 1, 2% Alternative Source of Care Rely Upon Family Member

Nothing Health Department Percentage Respondents by Their Mode of Transportation to the Health Services

85, 5% 36, 2%9, 0% 1, 2%1, 2%0, 0% 5, 0% 0, 0%

TARC TARC

Personal vehicle(car, Personal vehicle(car, motorcycle, bike) motorcycle, bike) Walking Walking

Car pool/Taxi/Share Car pool/Taxi/Share 1689, 93% ride ride Other Other 43, 96%

Health Department Percentage Respondents Who Identified DOCTOR OFFICE HOURS as a Big Barrier to Health Care

71, 4%

118, 4, 9% 5, 11% 7% Strongly Agree Strongly Agree 346, 19% Agree 5, 11% Agree 280, 16% Neutral Neutral Disagree 14, 31% Disagree Strongly Disagree 13, 29% Strongly Disagree 585, 32% 400, 22% No opinion No opinion

4, 9%

Health Department Percentage Respondents Who Identified TRANSPORTATION as a Big Barrier to Health Care

2, 4% 113, 6% 205, 12% Strongly Agree 4, 9% 7, 15% Strongly Agree 196, 11% Agree Agree Neutral Neutral 486, 27% 12, 27% 342, 19% Disagree 12, 27% Disagree Strongly Disagree Strongly Disagree No opinion No opinion 8, 18% 448, 25%

Health Department Percentage Respondents Who Identified KNOWING WHERE TO GO IN A HEALTH CARE FACILITY as a Big Barrier to Health Care

1, 2% 73, 4% 2, 4%

154, 228, 13% 5, 11% 8% Strongly Agree Strongly Agree Agree Agree Neutral Neutral 378, 21% 16, 36% 519, 29% Disagree 12, 27% Disagree Strongly Disagree Strongly Disagree No opinion No opinion 442, 25% 9, 20%

Health Department Percentage Respondents Identified COST OR EXPENCES as a Big Barrier to Health Care

38, 2% 52, 3% 27, 2% 1, 2% 0, 0% 78, 4% Strongly Agree Strongly Agree 4, 9% Agree 3, Agree 7% Neutral Neutral

495, 27% Disagree 22, 49% Disagree 1121, 62% Strongly Disagree Strongly Disagree No opinion 15, 33% No opinion

Health Department Percentage Respondents Who Identified DISCRIMINATION/BIAS as a Big Barrier to Health Care

95, 5% 1, 2% 171, 4, 9% 10% 172, Strongly Agree 6, 13% Strongly Agree 10% Agree Agree 8, 18% 390, 22% Neutral Neutral Disagree Disagree 559, 31% 13, 29% Strongly Disagree Strongly Disagree 13, 29% 395, 22% No opinion No opinion

Health Department Percentage Respondents Who Identified HEALTH KNOWLEDGE as a Big Barrier to Health Care

72, 4% 2, 5% 0, 0%

131, 7% Strongly Agree Strongly Agree 361, 20% Agree Agree 9, 20% 13, 30% 214, 12% Neutral Neutral Disagree Disagree 4, 9% 374, 21% Strongly Disagree Strongly Disagree 645, 36% No opinion No opinion 16, 36%

Health Department Percentage Respondents Identified HEALTH BELIEFS as a Big Barrier to Health Care

140, 8% 3, 119, 4, 9% Strongly Agree 7% Strongly Agree 7% 266, 15% Agree Agree Neutral 8, 18% Neutral 228, 13% 14, 31% Disagree Disagree 526, 29% Strongly Disagree Strongly Disagree 510, 28% 10, 22% No opinion No opinion 6, 13%

Health Department Percentage Respondents Who Identified INSURANCE ISSUES as a Big Barrier to Health Care

49, 3% 39, 2% 1, 2% 0, 0% 76, 4% 94, 5% Strongly Agree Strongly Agree 8, 18% Agree Agree Neutral 18, 40% Neutral 2, 4% Disagree Disagree 503, 28% 1053, 58% Strongly Disagree Strongly Disagree 16, 36% No opinion No opinion

Health Department Percentage Respondents Identified STIGMA as a Big Barrier to Health Care

2, 4%

192, 170, 3, 5, 11% 11% 9% Strongly Agree 7% Strongly Agree 173, Agree Agree 10% 295, 17% Neutral Neutral 10, 22% 285, 16% Disagree Disagree 18, 40% Strongly Disagree Strongly Disagree 667, 37% No opinion No opinion 7, 16%

Health Department Percentage Respondents Identified CULTURE AND LANGUAGE as a Big Barrier to Health Care

2, 4%

187, 202, 3, 10% 11% 7% 172, Strongly Agree 9, 20% Strongly Agree 10% Agree Agree Neutral Neutral 224, 13% 459, 26% Disagree 14, 31% Disagree Strongly Disagree 13, 29% Strongly Disagree No opinion No opinion 541, 30% 4, 9%

Health Department Percentage Respondents Identified MEDICAID RULES as a Big Barrier to Health Care

6, 13% 322, 18% 325, 18% Strongly Agree Strongly Agree Agree 14, 31% Agree 112, 6% Neutral Neutral 157, 9% 366, 21% Disagree 13, 29% Disagree Strongly Disagree Strongly Disagree No opinion No opinion 2, 5% 5, 11% 509, 28% 5, 11%

Health Department Percentage Respondents Identified FEAR OF DEPORTATION as a Big Barrier to Health Care

134, 7% Strongly Agree 6, 13% Strongly Agree

209, 12% Agree Agree 483, 27% 15, 34% Neutral 7, 16% Neutral Disagree Disagree 174, 10% 599, 34% Strongly Disagree Strongly Disagree 6, 13% 178, No opinion 5, 11% No opinion 10% 6, 13%

Health Department Percentage Respondents Relying upon Various Sources for Health Information

140, 8% Family and Friends Family and Friends 69, 4% 3, 7% 0, 0% 9, 0% Media (i.e., TV, radio, Media (i.e., TV, radio, 136, 0, 0% newspaper) 5, 11% newspaper) 7% Internet Internet

Health department Health department 13, 29% 592, 33% Hospital Staff Hospital Staff 830, 46% Doctor or Personal Physician 23, 51% Doctor or Personal Physician

Nurse, Nurse Practitioner, Nurse, Nurse Practitioner, Physician Assistant 0, Physician Assistant 10, 0% Other 0% Other 32, 2% 1, 2%

Health Department Percentage Respondents who Have Access to Preventive Health Services

59, 3%34, 2% 0, 0%

Yes Yes

No No

I don’t know I don’t know 1721, 95%

45, 100%

Health Department Percentage Respondents Who Feel They Have Enough Information to Know What to Expect When They Visit Health Care Facility

2, 5% 66, 4% 0, 0% 48, 3%

6, 13% 228, 12% Yes Yes No No Not Applicable Not Applicable I don’t know I don’t know 1477, 81% 37, 82%

Health Department Percentage Respondents Who Feel That Discharge Instructions Were Clear Enough for Them and Their Family to Help Recover While Their Last Discharge From a Health Care Facility

15, 1% 1, 2%

154, 9% 6, 14%

188, 10% Yes Yes

No No 10, 22% Not Applicable Not Applicable 28, 62% 1465, 80% I don’t know I don’t know

Health Department Percentage Respondents Who Feel That Health Providers Provide Them With Needed Education and Resources

38, 2% 75, 4% 0, 0% 0, 0%

Yes Yes 14, 31% 393, 22% No No Not Applicable Not Applicable

1312, 72% I don’t know 31, 69% I don’t know

Health Department Percentage Respondents Think They Were Seen in a Timely Manner During Their Visit to Health Care Facility

51, 3% 13, 1% 2, 4% 0, 0% 139, 7% 4, 9% Always Always 286, 16% Usually 9, 20% Usually Sometimes Sometimes Rarely Rarely 454, 25% 884, 48% 7, 16% Never 23, 51% Never No opinion No opinion

Health Department Smoking/Tobacco use

217, 11% 82, 4% Drug abuse 67, 4% Alcoholism Percentage 59, 3% 785, 40% a and b Respondents Who 82, 4% 30, b and c 2% a and C 301, 15% Identified All of the above None 336, 17% Addiction as Big No opinion/I don’t know Health Problem in

Their Smoking/Tobacco use 5, 11% Drug abuse Neighborhood Alcoholism 4, 9% 13, 29% 0, a and b 0% b and c 1, a and C 16, 36% 2% All of the above 3, 2, 4% 7% 1, 2% None No opinion/I don’t know

Health Department 40, 2% 31, 2% 107, 6% Anxiety 109, 17, 1% Depression 6% 5, 0% Bipolar disorder Percentage a and b 173, 9% b and c

Respondents Who 1075, 57% a and C 321, 17% All of the above Identified Mental None No opinion/I don’t Illness as Big Health know Problem in Their 1, 2% Anxiety 3, 7% Neighborhood 7, 16% Depression Bipolar disorder 7, 15% a and b b and c 3, 7% a and C 13, 29% All of the above 8, 18% None No opinion/I don’t know

1, 2% 2, 4%

Health Department 25, 1% 73, 4% 61, Asthma 3% COPD (Chronic Obstructive 166, 9% 12, Pulmonary Disease) 1% Emphysema 13, Percentage 1% a and b 197, 10% b and c Respondents 1074, 57% a and C 258, 14% All of the above

Identified Respiratory None Illness as Big Health No opinion/I don’t know Problem in Their

Asthma Neighborhood 1, 2% COPD (Chronic Obstructive 7, 16% 7, 16% Pulmonary Disease) Emphysema 0, 0% a and b 5, 11% 4, 9% b and c 1, 2% a and C 0, 0% All of the above 20, 44% None

No opinion/I don’t know Health Department 71, 4% 80, 4% 21, 1% 43, 2% Lung 16, 1% Breast 6, 0% Prostate Percentage 163, 9% a and b b and c 213, 12% Respondents a and C 1244, 67% All of the above

Identified Cancer None

No opinion/I don’t Type(s) as Big Health know Problems in Their Lung Neighborhood Breast 9, 20% Prostate 11, 24% a and b

3, 7% 0, b and c 0% 2, 5% a and C

3, 7% All of the above 1, 2% 15, 33% None

1, 2% No opinion/I don’t know

Health Department Diabetes/High blood sugar Heart disease (High blood 165, 130, 7% pressure, Heart attack) 9% 22, 1% Stroke

Percentage a and b

177, 9% b and c Respondents 999, 53% 9, 0% a and C 242, 13% All of the above Identified Other 3, 0% 148, None 8% Chronic Diseases as No opinion/I don’t know Big Health Problems

Diabetes/High blood in Their sugar Heart disease (High blood 1, 2% 5, 11% 4, 9% pressure, Heart attack) Neighborhood Stroke 4, 9% 0, 0% a and b

b and c 8, 18% a and C

20, 44% All of the above 3, 7% None

0, 0% No opinion/I don’t know

Health Department Obesity

HIV/AIDS Percentage 653, 36% All of the above 889, 48% Respondents Other Identified Emerging None No opinion/I don’t know 179, 10% Issues as Big 77, 4% 12, 1% 24, 1% Health Problems in

2, 4% 4, 9% Their Neighborhood 1, 2% Obesity HIV/AIDS All of the above

12, 27% 26, 58% Other

None

No opinion/I don’t know 0, 0% Health Department Percentage Respondents Feel Various Health Organizations in Their Community are Meeting the Health and Wellness Needs of Their Community

Yes Yes 11, 24% 13, 29% 550, 30% 601, 33% No No 0, 0% Not Applicable Not Applicable

I don’t know I don’t know 32, 2% 21, 47% 627, 35%

Health Department Percentage Respondents Who Think There are People in Their Community That Need Care but Cannot Get it

0, 0% 3, 7% 6, 0% 303, 17% 4, 9% Yes Yes

179, 10% No No Not Applicable Not Applicable 1332, 73% I don’t know I don’t know 38, 84%

Health Department Availability of health screenings (i.e., cancer screening) 68, 101, 5% More places to exercise 4% 148, 8% Access to fresh fruits and 205, 11% 31, 2% vegetables Percentage of Quit smoking classes 10, Respondent 0% Diabetes management classes More access to primary care doctor 215, 12% 884, 49% Considered Best More access to specialists 120, Nutrition education Ways to Address 7% 35, 2% Lower cost of health care and prescription drugs the Health No opinion/I don’t know

Availability of health screenings Needs of People (i.e., cancer screening) 1, 2% in Their 1, 2% More places to exercise 4, 9% Access to fresh fruits and vegetables Community Quit smoking classes 6, 13% Diabetes management classes 0, 0% More access to primary care doctor 22, 49% 7, 16% More access to specialists 0, 0% Nutrition education 3, 7% 1, 2% Lower cost of health care and prescription drugs Health Department No opinion/I don’t know Provide more education or Percentage prevention programs Provide more health care facilities Respondents 157, 9% or doctor/physician’s offices 350, 19% Provide more doctors/physicians 205, 11% Recommendation Easier access to health care 88, 5% 50, services 123, 7% 3% s on How can More funding for reduced cost or free services 242, 13% Provide health coach or navigator community/busin 587, 33% ess Leaders and Advocate for better health policy Heath Care No opinion/I don’t know

Organizations Provide more education or 0, 0% prevention programs Work Together to Provide more health care facilities or doctor/physician’s offices 8, 18% Meet Wellness 10, 22% Provide more doctors/physicians Easier access to health care services Goals 7, 16% 4, 9% More funding for reduced cost or free services 5, 11% Provide health coach or navigator

11, 24% 0, 0% Advocate for better health policy

No opinion/I don’t know Health Department 58, 3% Children and teens 125, 7% Young adults 176, 10% Percentage Immigrant and refugees 738, 41% Minority groups (i.e., African- Respondents 124, 7% American, Hispanic) Elderly

Opinion on a Lesbian, Gay, Bisexual and 473, 26% Transgender (LGBT) Group Needing Physical or Mentally disabled 88, 5% Low income families the Most Help 14, 1%

0, 0% with Access to Children and teens 3, 7% Young adults Health Care 3, 7% Immigrant and refugees 4, 9% Minority groups (i.e., African- American, Hispanic) Elderly 25, 57% 6, 13%

Lesbian, Gay, Bisexual and Transgender (LGBT) 3, 7% Physical or Mentally disabled 0, 0% Low income families Health Department Increase access to oral health 57, 3% services Increase opportunities for Percentage more exercise 255, 14% 268, 15% Increase access to fresh fruit and vegetables Respondents Increase access to special health care needs 166, 9% 394, 22% Increase access to mental and Opinion on What emotional health services 115, 6% More school nurses or school- based health centers We Need In Increase access to immunization services 27, 2% 435, 24% Increase health insurance Order to Improve 95, 5% coverage Children’s Health No opinion/I don’t know Increase access to oral health 1, 2% services in Louisville Increase opportunities for 3, 7% more exercise Increase access to fresh fruit Metro/Jefferson and vegetables 7, 16% 11, 24% Increase access to special County health care needs Increase access to mental and 0, emotional health services 0% 8, 18% More school nurses or school- based health centers 11, 24% Increase access to immunization services Increase health insurance 2, 5% coverage 2, 4% Health Department No opinion/I don’t know Comments

Respondent Comments by Category, CHNA 2012 140 121 120 115 108 100 100

80 73

39 40

20 14 7

N/A

ENW

Quality

Affordability Survey

Access

Environmental Health Environmental Accountability

Health Department Comments Cont..

Healthcare Access

35 31 30 27

20 17 15 14 15 12

10 5 5

Health Department Health Department Thank You

Health Department

Appendix C: 2012 LMPHW Public Survey

2012 COMMUNITY HEALTH NEEDS ASSESSMENT GENERAL POPULATION SURVEY

The purpose of this survey is to collect information regarding the health care needs of our community. All information is confidential and will be used to assist the health department to make program decisions and identify health priorities.

Instructions: For each question below, please circle the answer that you feel is most applicable to you and/or your family.

A. DEMOGRAPHICS

What is your Zip code? ______

1. What is your gender? a) Male b) Female c) Other/Transgender

2. What is your race? a) White e) American Indian/Alaska b) Black/African American Native c) Asian f) Other d) Native Hawaiian/Other Pacific g) Two or more races Islander

3. Are you Hispanic? a) Yes b) No

4. What language do you speak at home? a) English f) Korean b) Spanish g) Chinese c) German h) Amharic d) French i) Other e) Vietnamese

5. What is your age group? a) 18-24 years b) 25-34 years e) 55-64 years c) 35-44 years f) More than 65 years d) 45-54 years

B. ACCESS TO HEALTH CARE

1. Have you seen a primary care provider in the past 12 months? a) Yes b) No

2. Have you used the emergency room in the past 12 months for yourself or another adult in your household? a) 1 to 2 times b) 3 to 5 times c) 6 or more times d) None e) I don’t know

3. Have you used the emergency room in the past 12 months for a child under your care? a) 1 to 2 times b) 3 to 5 times c) 6 or more times d) None e) I don’t know f) Not applicable

4. The last time you had to use the emergency room, what was the reason? a) Non-emergency issue (rash, prescription refill, etc.) b) Urgent issue (cut, injury to joint, fever, etc.) c) Emergency (difficulty breathing, chest pain, seizures) d) Not applicable

5. Where do you go when you can’t see your regular healthcare provider? a) Urgent or Immediate Care Center b) Clinic in a grocery store or drug store c) Hospital Emergency Room d) Over the Counter/Pharmacist e) Folk Remedy f) Helpline g) Health Department h) See a Chiropractor or alternative source of care i) Rely upon family member j) Nothing 3

6. When you need to travel for health services, how do you get there? a) TARC b) Personal Vehicle (car, motorcycle, bike) c) Walking d) Car Pool/Taxi/Share Ride e) Other

7. Using the scale below, please check the box for each issue that you think is a big barrier(s) to health care in Louisville Metro/Jefferson County.

a) Strongly b) Agree c) Neither d) Disagree e) Strongly f) No Agree Agree or Disagree Opinion Disagree

1. Doctor’s Office Hours      

2. Transportation      

3. Knowing Where to Go      

in a Healthcare Facility

4. Cost or Expenses      

5. Discrimination/Bias      

6. Health Knowledge      

7. Health Beliefs      

8. Insurance Issues      

9. Stigma      

10. Culture and Language      

11. Medicaid Rules      

12. Fear of Deportation      

8. When I need health information, most often I rely upon the following source: a) Family and Friends b) Media (i.e., TV, radio, newspaper) c) Internet 4

d) Health Department e) Hospital Staff f) Doctor or Personal Physician g) Nurse, Nurse Practitioner, Physician Assistant h) Other

9. Do you have access to preventive health services (i.e., vaccination/shots, family planning, mammography or any other screenings, etc.)? a) Yes b) No c) I don’t know

C. PERCEPTION OF QUALITY OF HEALTH CARE

10. When you visit a health care facility for services do you feel you have enough information to know what to expect? a) Yes b) No c) Not applicable d) I don’t know

11. The last time you came home from a healthcare facility, did you feel that discharge instructions were clear enough for you and your family to help you recover? a) Yes b) No c) Not applicable d) I don’t know

12. Do you feel that health providers provide you with the education and resources you may need? a) Yes b) No c) Not applicable d) I don’t know

13. How often do you feel that when you have a medical appointment (i.e. diagnostic test, medical exam, doctor’s visit) you are seen in a timely manner during your visit? a) Always b) Usually c) Sometimes d) Rarely e) Never f) No Opinion 5

D. COMMUNITY HEALTH NEEDS

14. What are the biggest health problems in your neighborhood?

Addiction: a) Smoking/Tobacco Use b) Drug Abuse c) Alcoholism d) a and b e) b and c f) a and c g) All of the above h) None i) No opinion/I don’t know

Mental Illness: a) Anxiety b) Depression c) Bipolar Disorder d) a and b e) b and c f) a and c g) All of the above h) None i) No opinion/I don’t know

Respiratory Illness: a) Asthma b) COPD (Chronic Obstructive Pulmonary Disease) c) Emphysema d) a and b e) b and c f) a and c g) All of the above h) None i) No opinion/I don’t know

Cancer Types: a) Lung b) Breast c) Prostate d) a and b e) b and c f) a and c g) All of the above h) Other type of cancer 6

i) None j) No opinion/I don’t know

Other Chronic Diseases: a) Diabetes/High Blood Sugar b) Heart Disease (High Blood Pressure, Heart Attack) c) Stroke d) a and b e) b and c f) a and c g) All of the above h) None i) No opinion/I don’t know

Emerging Issues: a) Obesity b) HIV/AIDS c) All of the above d) Other e) None f) No opinion/I don’t know

15. Do you feel the various health organizations in your community are meeting the health and wellness needs of your community? a) Yes b) No c) Not applicable d) I don’t know

16. Do you think there are people in your community that need care but cannot get it? a) Yes b) No c) Not applicable d) I don’t know

17. In your opinion, what is the best way to address the health needs of people in your community? Please choose one option. a) Availability of health screenings (i.e., cancer screenings) b) More places to exercise c) Access to fresh fruit and vegetables d) Quit smoking classes e) Diabetes management classes f) More access to primary care physicians g) More access to specialists h) Nutrition education i) Lower cost of health care and prescription drugs j) No opinion/I don’t know

18. How can community/business leaders and heath care organizations work together to meet wellness goals? Please choose one option. a) Provide more education or prevention programs b) Provide more health care facilities or doctor/physician’s offices c) Provide more doctors/physicians d) Easier access to health care services e) More funding for reduced cost or free services f) Provide health coach or navigators g) Advocate for better health policy h) No opinion/I don’t know

19. Which group do you feel needs the most help with access to health care? a) Children and Teens b) Young Adults c) Immigrant and Refugees d) Minority Groups (i.e., African-American, Hispanic) e) Elderly f) Lesbian, Gay, Bisexual and Transgender (LGBT) g) Physically or Mentally Disabled h) Low-Income Families

20. In order to improve children’s health in Louisville Metro/Jefferson County what do we need to do?

a) Increase access to oral health services b) Increase opportunities for more exercise c) Increase access to fresh fruit and vegetables d) Increase availability of special health care needs e) Increase access to mental and emotional health services f) More school nurses or school-based health centers g) Increase access to immunization services h) Increase health insurance coverage i) No opinion/I don’t know

21. What did we miss or not ask you about health related issues in our county? WRITE ON COMMENT CARD

Thank you for your participation!

Appendix D: 2011 Louisville Metro Health Equity Report

LOUISVILLE METRO HEALTH EQUITY REPORT The Social Determinants of Health in Louisville Metro Neighborhoods

2011 LOUISVILLE METRO HEALTH EQUITY REPORT The Social Determinants of Health in Louisville Metro Neighborhoods

This report was produced by the Metro Department of Public Health and Wellness’ Center for Health Equity. The Center for Health Equity works to address the root causes of health disparities by supporting projects, policies and research working to change the correlation between health and longevity and socioeconomic status.

Authors: Patrick Smith, AICP Margaret Pennington, MSSW Lisa Crabtree, MA Robert Illback, PsyD

REACH of Louisville, Inc. www.reachoﬂ louisville.com

Comments, questions, and requests for additional information can be directed to: C. Anneta Arno, PhD, MPH Director, Center for Health Equity Louisville Metro Department of Public Health and Wellness 2422 West Chestnut St. Louisville, KY 40211 (502) 574-6616

Design: REACH of Louisville, Inc.

Cover Photo Credits: Child on Bicycle - © Photo courtesy of Louisville Metro Group exercising - © Courier Journal All other photos courtesy of the UofL Urban Design Studio

EXECUTIVE SUMMARY The social and physical conditions into which people are born, live and work, profoundly THE SOCIAL DETERMINANTS OF affect well-being and longevity. The inÀ uence of place and neighborhood is increasingly HEALTH ARE THE seen as a major, if not the most signi¿ cant, determinant of health. Thanks to a growing record SOCIAL, ECONOMIC, & of research and reporting, the body of evidence continues to amass on how the shape and PHYSICAL CONDITIONS fabric of communities and neighborhoods impact our health. Rather than simply functioning THAT CONTRIBUTE OR as the setting for interventions designed to change individual health and health behavior, DETRACT FROM THE community environments must be understood to have at least equal importance as health HEALTH OF PEOPLE AND determinants. NEIGHBORHOODS

Much of the research on place and health has been articulated through a set of constructs termed “the Social Determinants of Health” (SDOH). The SDOHs consider how social Income & and neighborhood conditions come together to impact health outcomes. Research has Employment demonstrated that access to proven health protective resources like clean air, healthy food, recreational space, opportunities for high-quality education, living wage employment, and decent housing, is highly dependent on the neighborhood where one lives. Some of the implications for Louisville described in the report are as follows:

Louisvillians in the poorest neighborhoods have lower life expectancies, sometimes by as much as ten years shorter Environmental Quality than the overall Louisville Metro life expectancy (see page 5).

Louisville residents ages 40-65 who earn less than $20,000 annually are signiÀ cantly more likely to report that they have had a heart attack (see page 17).

Neighborhoods that have been labeled as “food deserts” have diabetes mortality rates that are two to three times higher than the total Louisville Metro rate (see pages 15 and 38-41).

Opportunities for physical activity in some neighborhoods could be impeded by safety issues including hazards for Food pedestrians and bicyclists, or high rates of violent crime Access in or near public parks (see pages 37 and 51).

Health The primary goal of the Louisville Metro Health Equity Report is to promote a community- Care wide understanding of the root causes of health inequities in Louisville Metro. It can also Access serve as an impetus for discussing the neighborhood conditions that contribute to health in all of Louisville’s neighborhoods. Key to fostering this understanding is thoughtful engagement with health and social determinant data and research. The research and data Community accumulated within this report should be of broad interest to community members, but our Safety greater desire is that the ¿ ndings portrayed within the report will be used to move discussions beyond individual choice-making toward the underlying community environmental factors Parks & that perpetuate poor health. Physical Activity CONTENTS

INTRODUCTION ...... 2 Place Matters and Neighborhood Counts...... 2 Health Equity Report Framework ...... 3 The Social Determinants of Health ...... 3 Social Inequalities, Structural Racism, and the Social Determinants ...... 4 Historical Context ...... 6 Report Methodology ...... 7

DEMOGRAPHICS...... 8

HEALTH STATUS ...... 12

INCOME & EMPLOYMENT...... 16

HOUSING ...... 22

ENVIRONMENTAL QUALITY ...... 27

EDUCATION ...... 31

TRANSPORTATION ...... 35

FOOD ACCESS ...... 38

HEALTH CARE ACCESS ...... 41

COMMUNITY SAFETY ...... 46

PARKS & PHYSICAL ACTIVITY ...... 50

CONCLUSION ...... 52

REFERENCES ...... 53

Appendix A: Neighborhood Area Detail Maps...... 59

Appendix B: Work Group Listings ...... 68

Special thanks to the National and Local Work Groups: See Appendix for listing.

Special thanks to Catherine Fosl, PhD for contributions for Louisville’s historical context, and to Ray Yeager, MPH for analysis on age-adjusted life expectancies and mortality rates. LIST OF FIGURES

Adult Report of Heart Disease & Heart Attack, 2009…………………...... ………..……13

Age-Adjusted Cancer Incidence (New Cancers) Rates per 100,000 ……....…...... …….14

Adults Diagnosed with Diabetes, 2009 ……………………………...... ……15

Income Below Poverty Level, 2009 ………………...... …..16

Per Capita Income by Race/Ethnicity, Louisville MSA, 2009 …………...... …………...17

Heart Attacks, By Income, 2009 …...... …17

Hourly Wages in Louisville Metro, 2008 …………………...... …18

Estimated Unemployment Rates, by Race/Ethnicity, 2005-2009 ...... ………………18

Self-Reported Poor Health by Employment Status, Ages 18-64, 2009 …...... …………….18

Health Insurance Coverage by Employment Status, 2009 ……………...... ………….19

Households with Assistance Income in Louisville Metro, 2009...... …………………19

Fair Market Rents for Louisville Metro, 2001-2011 ………………...... …………………22

Homeowners by Race/Ethnicity, 2007-2009 ...... …...... 23

Home Purchase Loans Denied by Race/Ethnicity and Income, 2009 ...... ……………….24

People Ages 25-65 Reporting ‘Good’ or ‘Excellent’ Health, by Education Level, 2009 ...... 31

People Ages 25-65 Reporting Risk Behaviors, 2009 …...... ………..31

People Ages 25-65 Reporting Chronic Conditions, 2009 ...... …………………32

Birth Outcomes by Mother’s Education Level, 2008-2009 ...... ……………………….32

Average Annual Pedestrian Deaths per 100,000, 2000-2009 ...... ……………………36

Percent without Any Type of Health Coverage, Ages 25-65, 2009 ...... ……………………41

Percent with Any Type of Health Coverage, 2002-2009 …...... ………….42

Adults with 20+ Minutes of Vigorous Physical Activity 3+ Days per Week, 2009 ...... ………….50 LIST OF MAPS Age-Adjusted Life Expectancy, in Years, 2006-2008…...... 5 White, One Race, 2005-2009 …………...... ………………………8 Black or African American, One Race, 2005-2009 ...... ………..….…..8 Hispanic or Latino, of Any Race, 2005-2009.………………...... ……………………………..………9 Asian, 2005-2009 …………...... ……………………………………………………………..……..9 People Ages 65 & Over, 2005-2009 …...... …………………………………………………….………..…….10 Children Under Age 5, 2005-2009 …...... …………………………………………….…………..…10 Households Where Grandparent Is Responsible for Own Grandchildren Under 18 Years 2005-2009, …...... ….11 Foreign Born Population, 2005-2009 ……………...... ……....………………………………………..…11 Deaths Due to All Causes (Age-Adjusted Rate per 100,000 Population), 2006 -2008 ……...... …………....12 Deaths Due to Diseases of the Heart (Age-Adjusted Rate per 100,000 Population), 2006 -2008 …...... …...13 Deaths Due to Cancer (Age-Adjusted Rate per 100,000 Population), 2006 -2008 …………...... …..….…14 Deaths Due to Diabetes (Age-Adjusted Rate per 100,000 Population), 2006 -2008 ………...... ………...….15 Unemployment (Civilian Labor Force, Ages 16 and Older), 2005-2009 …………………...... ………….….20 Families Earning Less than $15,000 (Income & Benefi ts in 2009 Infl ation Adjusted Dollars) 2005-2009 ...... …21 Foreclosure Auctions, 2009 ……...... …...... ……………………………………………………………23 Foreclosure Rate (Estimated Foreclosure Starts/Estimated Number of Mortgages), 2007- June 2008 ...... ……25 Renters Paying 35% or More Households Paying 35% or More of Income for Rent), 2005-2009 ...... ……...26 Respiratory Risk from On-Road Pollution Source, 2002 ……………….…...... …………………...28 Total Respiratory Risk from All Sources, 2002 …………………….....…...... ……………………….28 On-site Toxic Releases from Facilities, 2009 ……………………………...... ………………………….29 Pre 1950’s Housing (Percentage of Older Housing Stock per Neighborhood Area), 2005-2009 …...... ……...30 Ninth Grade Education or Less (25 or Older with 9th Grade Education or Less), 2005-2009 ………...... ………33 College Degree or Higher (25 or Older with at Least a Bachelor’s Degree), 2005-2009 ...... ……………………..34 Bicycle and Pedestrian Collisions, (Rate per 1000 people), 2009 ………...... ………………………..37 Fast Food Outlet Density, (Number of Fast Food Outlets per Mile), 2010 …...... ……………………40 Federally Qualifi ed Health Centers and LMPHW Preventative Health Clinics …...... ……….…….42 Language Other than English Spoken at Home, Population 5 Years and Over 2005-2009 ………...... 44 No Vehicles Available, Occupied Housing Units with No Vehicles, 2005-2009 ………...... ………….…….45 Package Liquor Store Density, (Package Liquor Stores per Square Mile) …………...... …………….…….47 Serious Crimes, Rate per 10,000, (Assaults, Burglaries, and Homicides), 2010 …………...... ……………48 Vacancy Rates, (Residential Vacancies/Total Residences), 2010 ………………………...... …….…………49 Assaults within 1000 ft of Metro Parks, (Rate per 10,000 People), 2010 ……...... …………………..51 TECHNICAL NOTE The demographic and Social Determinant data in this report are depicted using groups of Census 2000 tracts that correspond to data from the 2005-2009 American Downtown- Community Survey Estimates. These groups of Census Phoenix Hill- Old Louisville- Tracts attempt to represent established city neighborhoods Smoketown- University Shelby Park and residential communities or areas of the county (see page 7 for a more detailed description). Northeast Chickasaw- Portland Butchertown-Clifton- Shawnee Crescent Hill St. Neighborhood Areas Russell Matthews California- Parkland Highlands Algonquin - Park Hill - 18 Park Duvalle German- town Southeast J-town Louisville South Shively Central Louisville Buechel-Newburg- Airport Indian Trail Fern South Louisville Creek

Pleasure Ridge Park Floyd’s Fork

Highview- Okolona Fairdale Valley Station

Miles

TECHNICAL NOTE 16 Downtown- Because Louisville Metro’s legislative Phoenix Hill- governance structure is conﬁ gured along Old Louisville- Smoketown- University Shelby Park Council District lines, a map overlaying both 17 the neighborhood and the Council District Northeast Chickasaw- Portland 7 boundaries has been provided. While the 5 Butchertown-Clifton- Shawnee St. overlapping lines make it difﬁ cult to read, Crescent Hill Russell 4 9 Matthews 19 hopefully it will serve as a reference for California- Parkland Highlands 18 those who base their work on current (2011) Algonquin - Park Hill6 - Park Duvalle German- 8 legislative boundaries. town 26 Southeast J-town Louisville 3 South 1 Shively Central 11 Louisville15 10 21 Buechel-Newburg- Airport Indian Trail 2 Fern South Louisville Creek 12 20 Pleasure Ridge Park Floyd’s Fork 24 25 Highview- 22 Okolona 13 23 Fairdale Valley Station

5 14 Neighborhood Areas Miles Council Districts, 2011

Metro Louisville Council Boundaries provided by LOJIC, Louisville/Jefferson County Information Consortium INTRODUCTION

Place Matters & healthy food, parks and opportunities for research. Data that illuminate the Neighborhood Counts physical activity. Collectively, they tend underlying conditions that perpetuate Social, physical, and economic to be manifested in places -- therefore health inequities at the community conditions shape the places into which place matters and neighborhoods count level are important to illustrate social we are born, and where we live, learn, in opportunities for health! and economic conditions that lead to work, play, and age. The characteristics health inequities in communities.2 The of a given neighborhood or community A social-determinants lens also helps to research and data accumulated within represent the interplay of contemporary shine light on the underlying ‘root causes’ this report should be of broad interest and historical burdens and benefi ts of health inequities. Health inequities are to community members, but our greater associated with these conditions. There unfair, avoidable, systemic differences desire is that its contents will be used are signifi cant differences in health in health status, morbidity and mortality to move discussions beyond individual status between groups in society who are rates. Social-determinants demonstrate choice-making toward the underlying economically and socially advantaged that the underlying cause of individual community environmental factors that and those who are not (due to factors and community health outcomes are not perpetuate poor health. such as socioeconomic status, race/ primarily the inevitable result of genes ethnicity, sexual orientation, gender, or individual health behaviors; nor the To achieve this broader goal, the Health and disability).1 Research now provides result of some ‘natural’ health-wealth Equity Report has three primary objectives: compelling evidence that group calculus. Neither is access to ‘health differences in health status are, at least care’ the primary driver. While genes, 1. To portray current social, economic and environmental factors associated with in part, attributable to the infl uence of health behaviors and access to care are inequities in health; place. Place is not merely the physical critically important, collectively, they location where one lives (and within contribute to only half of the entire 2. To assist local organizations in which health interventions occur); health equation. facilitating community dialogues place is a major determinant of risk regarding health inequities, focusing on root causes, rather than just individual and protective factors associated with Health Equity Report behaviors; health status and worthy of examination Framework in its own right. This is the essence of a The primary goal of the Louisville Metro 3. To encourage community-based social-determinants of health and health Health Equity Report is to promote actions related to social, economic, equity perspective. The underlying a community-wide understanding of and environmental determinants of determinants are pervasive, and are the root causes of health inequities in community health. evident in the quality and quantity Louisville Metro. It can also serve as an Health inequities are disparities in of housing (including the degree of impetus for discussing the community health or health care that are systemic residential segregation), education, conditions that contribute to health and avoidable, and therefore considered income and employment, transportation, in all of Louisville’s neighborhoods. unfair. Healthy People 2020 defi nes a natural and built environment, as well Key to fostering this understanding health disparity as “a particular type as community safety, and access to is thoughtful engagement with health and social determinant data and of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health “Health Equity is the attainment of the highest level of health for disparities adversely affect groups all people. Achieving health equity requires valuing everyone of people who have systematically equally with focused and ongoing social efforts to address experienced greater obstacles to avoidable inequalities, historical and contemporary injustices, health based on their racial or ethnic and the elimination of health and health care disparities.” group; religion; socioeconomic - Healthy People 2020

2 LOUISVILLE METRO HEALTH EQUITY REPORT status; gender; age; mental health; These social and physical factors are about health from those available to cognitive, sensory, or physical referred to as the Social Determinants of them. Individual choice is a factor; disability; sexual orientation or gender Health (SDOH), and through learning however, some environments do not identity; geographic location; or other more about the SDOH, community contain the health promoting resources characteristics historically linked to members can learn more about the root that are necessary for maintaining good discrimination or exclusion.”3 Different causes affecting health outcomes in health, such as grocery stores with neighborhoods in Louisville Metro can communities. fresh, affordable produce and parks that have very different health outcomes for are safe. Also, some neighborhoods their resident populations, and many of It is important to note that this report have a disproportionate concentration these differences are associated with operates under the understanding that of negative factors, including vacant social inequities related to income, race, health does not equal health care.5 buildings, crime, fast food retailers, or ethnicity, gender, or immigration status. Access to health care is a crucial need toxic polluting industries that can lead Poor health is concentrated among low that is addressed within the report, but to serious health problems and shorter income people and people of color it is not the most important determinant life spans for residents. residing in certain places.4 of good health. In fact, only “...10 to 15 percent of preventable mortality has This report seeks to elevate the The Louisville Health Equity Report been attributed to medical care.” 6 community discourse regarding health provides a baseline for understanding beyond issues of individual behavior the root causes of health inequities in There is a common perception that or access to medical treatment by Louisville Metro, and also serves as a individual behavior is the primary examining the relationships between mechanism for providing more localized determinant of health. This presumes social inequities and the neighborhood data about neighborhood conditions that some individuals choose to be conditions that shape overall health. that contribute to health outcomes. unhealthy, and that such choices are As the focus is narrowed to the places This report will examine income or within the control of every individual. where people live, rather than individual race based health inequities, and will This report counters this belief by citing choices and decisions, the inﬂ uence of also present indicators addressing the data that suggest that people are, in large social inequity becomes more clear. social and physical environment of part, the products of their environment, neighborhoods that contribute to health. and are often limited to making choices

The Social Determinants of Health Much of the research on place and health has been articulated through a set of constructs termed “the Social Determinants of Health” (SDOH). The SDOHs consider how social and neighborhood conditions come together to impact health outcomes. Research has demonstrated that access to proven health protective resources like clean air, healthy food, recreational space, opportunities for high- quality education, living wage employment, and decent housing, is highly dependent on the neighborhood where one lives.7

Health can also be affected by the presence of risk factors. For example, the lack of a supportive neighborhood environment can lead to social and psychological circumstances that work to cause long-term stress, anxiety, insecurity, low self-esteem, social isolation and lack of control over work and home life. These psychosocial risks accumulate during life and increase the chances of premature death.8

Neighborhoods where people live have been associated with all-cause mortality, cause-speciﬁ c mortality, coronary heart disease, low birth weight, perceived health status and rates of violent crime.9

Introduction 3 Brennan Ramirez LK, Baker EA, Metzler M. Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2008.

Social Inequalities status is evident across all races and federal housing policies that not only The Louisville Health Equity report ethnicities. This is demonstrated by the fact denied homeownership to urban African- continues the discussion surrounding that neighborhoods that are predominantly Americans but physically destroyed many the root causes of poor health outcomes white, but poor, will frequently have black neighborhoods under the policies along socioeconomic, racial and ethnic mortality rates equal to or greater than the of urban renewal.12 While it is beyond lines. These differences in health are mortality rates of neighborhoods of color the scope of this report to fully address strongly related to social inequities that with equal or higher income levels. An the history of structural racism in this have historically resulted in unequal example is the low life expectancy rates community and the full extent of its impact, opportunities to be healthy.10 in the predominantly white, low income this report will provide references to the Portland neighborhood of Louisville. impact of these forces on the root causes Life expectancy is shorter and many of health. diseases are more common further Structural Racism down the social ladder, as measured by Structural racism examines racial and Social Determinants socioeconomic status.11 ethnic impacts that stem from a history This report also provides information of disenfranchisement and policies that and indicators on determinants of health Though people of color often experience favored those in power. Consequently, the that have implications for the health of poorer health outcomes, these relationships origins of urban inequality for communities all Louisville’s neighborhoods, not just are by no means permanently ﬁ xed; the of color cannot be separated from structural those with poor health. Neighborhoods health impact of income and socioeconomic racism. An example is the history of that are above the poverty level and

4 LOUISVILLE METRO HEALTH EQUITY REPORT Age-Adjusted Life Expectancy, in Years, 2006-2008

67.3 - 70.5 Downtown- Old Louisville- Phoenix Hill- Smoketown- 70.6 - 74.1 University Chickasaw- Shelby Park 74.2 - 78.2 Shawnee Northeast Portland Butchertown-Clifton- 78.3 - 83.1 St. Crescent Hill Russell Matthews Airport California- Parkland Highlands Algonquin - Park Hill - Park Duvalle German- town Southeast J-town South Louisville Central Shively Louisville Buechel- Newburg-- Airport Fern Indian Trail South Creek Louisville Pleasure Ridge Park Floyd’s Fork Highview- Okolona

Fairdale Valley Station 5 Mile

LOUISVILLE METRO* LIFE EXPECTANCY IS 77.4 *Airport Census Tracts not included due to unreliabale ACS population estimates

In Jefferson County, the neighborhood in which one lives neighborhoods with lower concentrations of racial and can serve as a predictor of life ethnic minorities can also be affected by poor social expectancy. and physical conditions. Even though needs may not seem as immediate or apparent in these communities, they should nevertheless be addressed. For example, Neighborhoods that have the lowest low-density, large lot zoning policies can result in life expectancies are the same disconnected neighborhoods with poor accessibility neighborhoods with high levels of to health-promoting environments. Additionally, many poverty, crime, vacancies, payday Louisvillians live too far away from their job and lenders, and fast food retailers. from services and therefore spend too much time in their cars, resulting in measurable health detriments. Neighborhoods may not have concentrated poverty, These associations provide strong but they may be burdened with poor environmental evidence that the quality of the conditions including pollution or ﬂ ooding. While the social and physical environment problems of the relatively better off are not as immediate may play an important role in as those living in poverty, they also encounter determining the health of community preventable problems that could be addressed through 9 thoughtful and informed community design. residents.

Introduction 5 HISTORICAL CONTEXT

Many conditions in Louisville Metro neighborhoods were not allowed to eat in most restaurants or to try on today are not the result of chance or of individual clothing in downtown shops. In the area of housing, choice. They are the result of policies and widely a city ordinance segregated the races by law until held ideas that developed, in part, out of our nation’s 1917. Even when the ordinance was overturned, tragic history of slavery and racial discrimination. whites continued to act to keep blacks out of many That history has a continuing impact on the health residential areas through strategies that ranged of our community today, leaving Louisville with some from restrictive clauses in deeds to community-wide striking racial and economic disparities. petitions to outright violence.

In the fi rst generations of Louisville’s existence, Only people organizing together in massive social the practice of slavery stripped the vast majority of protest movements brought about long-overdue African American residents of any hope of economic and meaningful change in the years after WWII. advancement—this meant that no matter how hard Landmark civil rights laws (1964) and open housing they worked, they could not acquire wealth as other laws (1967) ended legal segregation and many Americans could. Slavery also deprived them of the forms of discrimination. Yet some unfair policies and most basic rights, including the rights to education practices continued, especially in housing, where and legal marriage. Even the city’s sizeable free whites remained resistant to living in neighborhoods black population—though it managed to grow and with an infl ux of African American residents (such thrive—was kept out of many occupations and as in Louisville’s western neighborhoods). In 1968, places, and barred from voting. a protest there against the actions of a white police offi cer turned violent; two teenagers were killed and The Civil War brought an increase to the city’s African numerous stores were looted and damaged. When American population as black soldiers fl ocked into the riots ended, white business owners decided the Union Army through its Louisville headquarters not to rebuild. They took their investments to other and toward the freedom the war achieved in 1865. parts of town. Many white churches followed suit. By 1900, Louisville had the nation’s seventh largest Increasingly, well-to-do people of both races moved concentration of African Americans among U.S. out as well. West Louisville, lacking the infusion of cities (19.1%), a population growth that brought commercial development or new resources, became overcrowding and new majority-black neighborhoods even more economically and racially isolated. While such as Smoketown, California, and “Little Africa.” county-wide busing after 1975 integrated area schools and widened educational opportunities, Although Black Louisvillians organized themselves many students returned to long-standing disparities and advanced socially, educationally and politically, in their neighborhoods. their opportunities remained limited by racial segregation and discrimination. Until World War II, This brief review of Louisville’s history will hopefully most black Louisvillians were unwelcome in higher- contribute to a fuller understanding of the social paying industrial jobs and were hired only for unskilled determinants of health and of the disparities that labor, domestic services, or in institutions catering exist among Louisville Metro neighborhoods. only to blacks. Prior to the 1960s, African Americans

6 LOUISVILLE METRO HEALTH EQUITY REPORT REPORT METHODOLOGY Literature Review overcome the mismatch. In the core of measures that were the best proxies for In understanding the critical importance the city, neighborhood areas were kept social determinants of health. Mortality of social and physical environments in relatively small in population size and data from Kentucky Vital Statistics was spatial area in an attempt to maintain determining population health outcomes, averaged for the years 2006-2008 (the historical distinctions between places.” this report will present recent research latest fi nal versions available at the time 13 that illustrates the connections between of report productions). place and health. For organizing data at the sub-county Many of the Social Determinant level, the report chooses to use indicators were derived from the 2005- Social Inequities & Neighborhood Areas rather than Zip 2009 American Community Survey Health Outcomes Codes or Council Districts for a number (ACS) Estimates, which are available at This report includes recent data from of reasons. The most important reason the Census Tract level (using Census 2000 the Centers for Disease Control and being that the Neighborhood Areas help Tract boundaries). Beginning with Census Prevention (CDC) Behavioral Risk connect the statistics to the actual places 2010, the Census Bureau began replacing Factor Surveillance System (BRFSS)*, and people they are describing. When the traditional long form with data from organized by factors including race a Neighborhood Area is associated the ACS. But as the ACS data is a sample and income to illustrate the health with a particular indicator, the reader survey, it has a higher margin of error inequities experienced in low-income creates a mental picture much more than the prior collection method. For this neighborhoods and communities of color. easily than would be possible if Zip reason, Social Determinant indicators that Codes or Council Districts were the include population statistics for Census A local work group comprised of unit of enumeration. Further, most Zip Tracts in the ‘Airport’ Neighborhood Area community organizations and local Codes and Council Districts overlap and were not included due to unreliability agency representatives worked to identify segment traditional neighborhood areas associated with sampling very small the indicators and guide the primary across Louisville Metro. Any given Zip populations. content presented in this report. Code or Council District can contain bits and pieces of several traditional Many data sources were derived from state Social/Environmental Louisville neighborhoods that are often or local government agencies in list or Determinants & very different from one another socially, database formats that were geocoded and Louisville Neighborhood economically, or physically. However, analyzed using Geographic Information Areas compartmentalizing neighborhood Systems. These data include locations This report presents a range of social data is complex and imperfect, and of crimes, fast food outlets, bicycle and Neighborhood Area boundaries will not and environmental indicators for pedestrian collisions, etc. Neighborhood Areas in Louisville perfectly refl ect realities of everyday life in communities. Neighborhoods do not that provide localized data about the Most of the thematic map data depicted exist in isolation, but for the purpose of neighborhood conditions that contribute is this report is organized using the understanding some of the immediate to health. In this context, Neighborhood “Jenks” Natural Breaks data classifi ca- and powerful determinants of health Areas are defi ned as… tion method. This classifi cation statisti- inequities, it is helpful to artifi cially isolate cally determines the best arrangement the neighborhood context and examine it “… groupings of census tracts, of values into classes by seeking to neighborhood areas represent independent of the larger county-wide minimize each class’s average deviation established city neighborhoods and context. 14 from the class mean, while maximizing residential communities or areas of the each class’s deviation from the means of county. To improve statistical reliability, smaller city neighborhoods with similar Data Sources the other groups.The method reduces the populations were often combined into This report includes the most recent data variance within classes and maximizes a single neighborhood area. Census that could be analyzed at a sub-county the variance between classes. tract boundaries were sometimes level that was available at the time of not consistent with neighborhood report production. Within the available boundaries, but combining data sources, researchers selected the *See note regarding BRFSS neighborhoods often allowed us to data at the bottom of page 17

Introduction 7 SELECTED DEMOGRAPHICS

Race & Ethnicity

Downtown- Old Louisville- Phoenix Hill- Smoketown- University Chickasaw- Shelby Park Shawnee Northeast Jefferson Portland Butchertown-Clifton- St. Russell Crescent Hill Matthews California- Parkland Highlands Algonquin - Park Hill - Park Duvalle German- town Southeast J-town South Louisville Central Shively Louisville Percent of Population by Buechel- Newburg-- Neighborhood Who Are Airport Fern Indian Trail White, One Race South Creek Louisville

2005-2009 ACS Estimate 65 Pleasure Ridge Park Floyd’s Fork Highview- 5.6% - 10.5% 63 Okolona

10.6% - 64.6% 62 Fairdale Valley 64.7% - 87.5% 58 Station 5 87.6% - 95.0% Miles

Downtown- Old Louisville- Phoenix Hill- Smoketown- University Chickasaw- Shelby Park Shawnee Northeast Jefferson Portland Butchertown-Clifton- St. Russell Crescent Hill Matthews California- Parkland Highlands Algonquin - Park Hill - German- Park Duvalle town Southeast J-town South Louisville Central Shively Louisville Percent of Population by Buechel- Newburg-- Airport Fern Neighborhood Who Are Black or Indian Trail South Creek African American, One Race Louisville 2005-2009 ACS Estimate Pleasure Ridge Park Floyd’s Fork Highview- Okolona 1.8% - 4.9% Fairdale 5% - 13.9% Valley Station 5 14% - 59.6% Miles 59.7 - 92.4%

Residential Segregation: Black & White The Index of Dissimilarity compares the amount of spatial segregation or spatial dissimilarity between two populations (or ethnic/racial/immigrant groups) across geographic units that make up a larger geographic entity. The index ranges from 0 to 100, with 0 meaning no segregation or spatial disparity, and 100 being complete segregation between the two groups with no spatial overlap. The index of dissimilarity for the white and black populations of Metro Louisville Neighborhood Areas is 53%. This means that 53% of the black population would have to move in order for the white and black population to be spatially integrated.

8 LOUISVILLE METRO HEALTH EQUITY REPORT Percent of Population by Neighborhood Who Are Hispanic or Latino, of Any Race 2005-2009 ACS Estimate Downtown- 0.5% - 1.0% Old Louisville- Phoenix Hill- Smoketown- University Chickasaw- Shelby Park 1.1% - 1.7% Shawnee Northeast Jefferson 1.8% - 4.3% Portland Butchertown-Clifton- St. Russell Crescent Hill Matthews 4.4% - 8.0% California- Parkland Highlands Algonquin - Park Hill - Park Duvalle German- town Southeast J-town South Louisville Central Shively Louisville Buechel- Newburg-- Airport Fern Indian Trail South Creek Louisville

Pleasure Ridge Park Floyd’s Fork Highview- Okolona

Fairdale Valley Station 5

Miles

Percent of Population by Neighborhood Who Are Asian Downtown- Old Louisville- Phoenix Hill- Smoketown- 2005-2009 ACS Estimate University Chickasaw- Shelby Park Shawnee Northeast 0% - 0.1% Jefferson Portland 0.2% - 0.8% Butchertown-Clifton- St. Russell Crescent Hill Matthews California- 0.9% - 2.2% Parkland Highlands Algonquin - Park Hill - Park Duvalle German- 2.3% - 3.9% town Southeast J-town South Louisville Central Shively Louisville Buechel- Newburg-- Airport Fern Indian Trail South Creek Louisville

Pleasure Ridge Park Floyd’s Fork Highview- Okolona

Fairdale Valley Station 5

Miles Census Deﬁ nition of Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. It includes people who indicate their race as “Asian Indian,” “Chinese,” “Filipino,” “Korean,” “Japanese,” “Vietnamese,” and “Other Asian” or provide other detailed Asian responses. http://quickfacts.census.gov/qfd/meta/long_RHI405210.htm

Selected Demographics 9 Age

Percent of People Age 65 & Over Downtown- by Neighborhood Old Louisville- Phoenix Hill- Smoketown- University 2005-2009 ACS Estimate Chickasaw- Shelby Park Shawnee Northeast Jefferson 6.2% - 9.6% Portland Butchertown-Clifton- St. Russell Crescent Hill Matthews 9.7% - 13.3% California- Parkland Highlands Algonquin - Park Hill - 13.4% - 17.2% Park Duvalle German- town Southeast J-town 17.3% - 24.3% South Louisville Central Shively Louisville Buechel- Newburg-- Airport Fern Indian Trail South Creek Louisville

Pleasure Ridge Park Floyd’s Fork 65 Highview- Okolona 63 Fairdale Valley 62 Station 5 58 Miles

Downtown- Old Louisville- Phoenix Hill- Smoketown- University Chickasaw- Shelby Park Shawnee Northeast Percent of Children Under Age 5 Jefferson by Neighborhood Portland Butchertown-Clifton- St. 2005-2009 ACS Estimate Russell Crescent Hill Matthews California- Parkland Highlands Algonquin - Park Hill - 2.3% - 3.5% Park Duvalle German- town Southeast J-town 3.6% - 6.5% South Louisville Central Shively Louisville 6.6% - 11.1% Buechel- Newburg-- Airport Fern Indian Trail 11.2% - 16.8% South Creek Louisville

Pleasure Ridge Park Floyd’s Fork Highview- Okolona

Fairdale Valley Station 5

Miles

10 LOUISVILLE METRO HEALTH EQUITY REPORT Selected Demographics

Percent of Households where Grandparent is Responsible for Own Grandchildren under 18 Downtown- Old Louisville- Phoenix Hill- Smoketown- Years by Neighborhood University Chickasaw- Shelby Park 2005-2009 ACS Estimate Shawnee Northeast Jefferson Portland Butchertown-Clifton- St. Russell Crescent Hill Matthews 0.1% - 1.3% California- Parkland Highlands 1.4% - 3.2% Algonquin - Park Hill - Park Duvalle German- town Southeast J-town 3.3% - 6.1% South Louisville Central Shively Louisville 9.0% Buechel- Newburg-- Airport Fern Indian Trail South Creek Louisville

Pleasure Ridge Park Floyd’s Fork Highview- Okolona 65 Fairdale 63 Valley Station 5

62 Miles 58

Downtown- Old Louisville- Phoenix Hill- Smoketown- University Chickasaw- Shelby Park Shawnee Northeast Jefferson Percent of Foreign Born Population Portland by Neighborhood Butchertown-Clifton- St. Russell Crescent Hill Matthews 2005-2009 ACS Estimate California- Parkland Highlands Algonquin - Park Hill - Park Duvalle German- 0.2% - 2.4% town Southeast J-town South Louisville Central 2.5% - 5.1% Shively Louisville Buechel- 5.2% - 8.5% Newburg-- Airport Fern Indian Trail South Creek 13.4% Louisville

Pleasure Ridge Park Floyd’s Fork Highview- Okolona

Fairdale Valley Station 5

Miles

Selected Demographics 11

HEALTH STATUS - Selected Mortality & Disease Rates Deaths Due to All Causes (Age-Adjusted Rate per 100,000 Population) { 2006 -2008 Vital Statisitcs

1572 Portland In a 2003 study involving blacks, Mexican- 1528 Fairdale Americans, and whites in the United States, Algonquin-Park Hill mortality rates for all gender and racial/ 1500 -Park Duvalle ethnic groups were two to four times higher Phoenix Hill-Smoketown for those with the lowest incomes who lived 1418 -Shelby Park in the lowest SES neighborhoods compared 1404 California-Parkland with those with the highest incomes who 1378 Russell lived in the highest SES neighborhoods.

South Central Louisville 1217 Deaths would hypothetically be reduced by 1178 Fern Creek about 20% for each subgroup if everyone had the same death rates as those living in the 1085 Shively highest SES neighborhoods. Downtown-Old Louisville 1065 -University Winkleby MA, and Cubbin C. (2003). J Epidemiol Chickasaw-Shawnee 1064 Community Health. 2003 Jun;57(6):444-52. 1028 Pleasure Ridge Park 1007 Germantown Louisville Metro* rate is 832 South Louisville 899 *not including Airport Census Tracts Buechel-Newburg 896 -Indian Trail Downtown- Old Louisville- Phoenix Hill- Smoketown- University 860 Valley Station Chickasaw- Shelby Park Shawnee Northeast Jefferson 858 Highlands Portland Butchertown-Clifton- St. Butchertown-Clifton Russell Crescent Hill Matthews 837 -Crescent Hill California- Parkland Highlands 837 Highview-Okolona Algonquin - Park Hill - Park Duvalle German- town Southeast J-town Floyd's Fork South Louisville 820 Central Shively Louisville 691 Southeast Louisville Buechel- Newburg-- Airport Fern Indian Trail 661 J-town South Creek Louisville Northeast 617 Pleasure Ridge Park Jefferson Floyd’s Fork Highview- 561 St. Matthews Okolona

Fairdale Valley Station 5

Miles

12 LOUISVILLE METRO HEALTH EQUITY REPORT Deaths Due to Diseases of the Heart (Age-Adjusted Rate per 100,000 Population) 2006 -2008 Vital Statistics 677 Fairdale

555 Fern Creek Adult Report of Heart Disease or Heart Attack 466 Portland Adult Report of Coronary Heart Disease 408 California-Parkland 2009 CDC BRFSS 6.0% 387 Pleasure Ridge Park 4.7% 3.8% Algonquin-Park Hill 373 -Park Duvalle 342 Shively US Kentucky Louisville Metro 328 Germantown Adult Report of Heart Attack 318 Chickasaw-Shawnee 2009 CDC BRFSS 5.9% South Central Louisville 4.6% 315 4.0% Phoenix Hill-Smoketown 309 -Shelby Park US Kentucky Louisville 287 South Louisville Metro 282 Downtown-Old Louisville -University 259 Russell 248 Floyd's Fork Louisville Metro* rate is 236 233 Buechel-Newburg -Indian Trail *not including Airport Census Tracts 232 Highview-Okolona Downtown- Old Louisville- Phoenix Hill- Smoketown- University Chickasaw- Shelby Park 220 Valley Station Shawnee Northeast Jefferson Butchertown-Clifton Portland 219 Butchertown-Clifton- St. -Crescent Hill Russell Crescent Hill Matthews California- 200 Highlands Parkland Highlands Algonquin - Park Hill - Park Duvalle German- 198 Northeast Jefferson town Southeast J-town South Louisville Central 195 Southeast Louisville Shively Louisville Buechel- Newburg-- J-town Airport Fern 173 Indian Trail South Creek Louisville 145 St. Matthews Pleasure Ridge Park Floyd’s Fork Highview- Okolona

Fairdale Valley Station 5

Miles

Health Status 13 Deaths Due to Cancer, All Types (Age-Adjusted Rate per 100,000 Population) 2006 -2008 Vital Statisitcs 677 555 318 California-Parkland Algonquin-Park Hill 302 -Park Duvalle 293 Phoenix Hill-Smoketown Age-Adjusted Cancer Incidence -Shelby Park (New Cancers) Rates per 100,000, 285 Russell Kentucky Cancer Registry 2006-2008

275 South Central Louisville

265 Fern Creek Kentucky 559

262 Fairdale 259 Portland Louisville Metro 580 228 Shively 0 100 200 300 400 500 600 Downtown-Old Louisville 226 -University

218 Germantown Louisville Metro* rate is 189 215 Pleasure Ridge Park *not including Airport Census Tracts 213 Highview-Okolona 206 Chickasaw-Shawnee

South Louisville 203 Downtown- Old Louisville- Phoenix Hill- Smoketown- Buechel-Newburg University 196 -Indian Trail Chickasaw- Shelby Park Shawnee Northeast Jefferson 191 Valley Station Portland Butchertown-Clifton- St. Butchertown-Clifton Russell Crescent Hill Matthews 186 -Crescent Hill California- Parkland Highlands Algonquin - Park Hill - Floyd's Fork Park Duvalle 175 German- town Southeast J-town South Louisville 170 Southeast Louisville Central Shively Louisville J-town Buechel- Newburg-- 158 Airport Fern Indian Trail South Creek 154 Highlands Louisville Pleasure Ridge Park St. Matthews Floyd’s Fork 154 Highview- Okolona 146 Northeast Jefferson Fairdale Valley Station 5

Miles

14 LOUISVILLE METRO HEALTH EQUITY REPORT Deaths Due to Diabetes (Age-Adjusted Rate per 100,000 Population) 2006 -2008 Vital Statisitcs

466 Algonquin-Park Hill 82 -Park Duvalle Adults Diagnosed with Diabetes, Phoenix Hill-Smoketown 2009 CDC BRFSS 77 -Shelby Park 15 59 Portland

51 California-Parkland 12 13.0% 11.5% 48 South Central Louisville 9 8.3% 48 Germantown 6 Downtown-Old Louisville 46 -University 3 46 Shively 0 Fairdale US Kentucky Louisville 46 Metro 45 Valley Station

Pleasure Ridge Park 45 Louisville Metro* Chickasaw- rate is 28 43 Shawnee *not including Airport Census Tracts 41 Russell

38 Fern Creek

Buechel-Newburg Downtown- Old Louisville- Phoenix Hill- 34 -Indian Trail Smoketown- University Chickasaw- Shelby Park South Louisville Shawnee Northeast 31 Jefferson Portland 30 Highview-Okolona Butchertown-Clifton- St. Russell Crescent Hill Matthews California- 25 Floyd's Fork Parkland Highlands Algonquin - Park Hill - Park Duvalle German- town 22 Highlands Southeast J-town South Louisville Central Butchertown-Clifton Shively Louisville 22 -Crescent Hill Buechel- Newburg-- Airport Fern Southeast Louisville Indian Trail 19 South Creek Louisville

16 J-town Pleasure Ridge Park Floyd’s Fork Highview- 16 Northeast Jefferson Okolona

St. Matthews Fairdale 11 Valley Station 5

Miles

Health Status 15 INCOME & EMPLOYMENT

Poverty and Health pressure, obesity, weakened immune The ﬁ ndings from research about the system. links between poverty and poor health • Chronic diseases like diabetes, heart outcomes are compelling: Poverty in Louisville Metro disease, and many types of cancer. • People who are poor face increased In Louisville Metro, 12.7% of all odds of developing disease. Income • Infectious diseases ranging from HIV/ families have incomes below the and wealth are the strongest AIDS to seasonal ﬂ u. poverty level, and 15.7% of all determinants of positive health people have incomes below the outcomes, and the strength of this • Disabilities like blindness, mental poverty level.7 Both measures for 1 relationship is increasing. illness and decline of physical Jefferson County are higher than the strength. national rates of 10.5% and 14.3% • Lower socioeconomic status respectively. is adversely associated with psychosocial factors linked to In Louisville, poverty rates for Blacks coronary heart disease, particularly and Hispanics are nearly three times hostility and depression.2 higher than the poverty rates of • Heart and lung diseases are whites. disproportionately found among those living in low income households.3 Income Below Poverty Level, • Both individual poverty and 2009 ACS ESTIMATE neighborhood poverty are associated with poorer health outcomes.4 BLACK OR 31.9% AFRICAN • Poverty limits access to health- AMERICAN promoting resources, including ALONE access to healthy food and favorable housing, as well as adequate medical care and stable health insurance.5 HISPANIC People lower on the socioeconomic OR 31.7% LATINO scale are more likely to experience:6

• Newborn health problems like premature birth, low birth weight, and birth defects. WHITE ALONE 11.1% • Signs of future disease like high blood

In terms of dollars, federal poverty guidelines are set each year by the U.S. Department of Health & Human Services as a national measure used to determine eligibility for an array of programs and services. These guidelines are sometimes referred to as the Federal Poverty Level, or FPL. The 2009 poverty level for one person is $10,830 in annual income and $22,050 for a family of four (U.S. Dept. of Health & Human Services. www.aspe.hhs.gov).

16 LOUISVILLE METRO HEALTH EQUITY REPORT Income Inequality Per Capita Income by Race/Ethnicity, and Health Louisville Metropolitan StaƟ sƟ cal Area (MSA), 2009 Poverty is by itself a risk factor, but the size of the gap between those with high $27,447 incomes and those at the lower end $16,897 of the economic scale appears to pose $12,410 additional risks. A growing amount of research shows that health outcomes are WHITE BLACK OR HISPANIC AFRICAN directly connected to how evenly income AMERICAN is distributed across the population.8 While the reasons for this are still being Income Inequality explored, some researchers believe that The gap between rich and poor is increasing at a high larger rich-poor gaps may lead to spatial rate in Kentucky. A study released in 2007 showed that concentrations of race and poverty that from the late 1990s to the mid 2000s, the poorest 20% 9 lead to poorer health outcomes. saw their incomes fall by 9.7%, and families in the middle income range saw decreases of 5.8%, while the drop for those at the top was only 1.3%.10

One example of the higher rates of disease Heart Attacks by Income among people living in poverty is evident 25% Percentage of People Ages 40-65 in the chart to right.The chart shows ReporƟ ng a Heart AƩ ack, By Income+ that for BRFSS* respondents ages 40- 20% Louisville Metro BRFSS, 2009 65 in Jefferson County (2009), the rate 15% of people who report having had a heart

attack who live in households making less 10%

REPORTED 11.6% than $20,000 is more than twice that of HEART ATTACKS respondents in households making more 5% than $20,000. 3.6% 4.2% 0% Less than $20K to More than $20K $35K $35K n = 251 n = 194 n = 359 +Respondents earning less than $20K annually INCOME are more likely to report a heart attack x2 = 15.6, df = 2, p-value = 0.0004

*The Behavioral Risk Factor Surveillance System (BRFSS) is performed under the auspices of the Centers for Disease Control and Prevention (CDC). This state-based telephone surveillance system is designed to collect data on individual risk behaviors and preventive health practices related to the leading causes of morbidity and mortality in the United States. The version of the BRFSS used in this report was administered by the KY Department of Public Health, and made available by the CDC. The Louisville Metro Department of Public Health and Wellness uses the same survey instrument in selected years, but did not administer the BRFSS in 2009.

Income & Employment 17 Lack of job opportunities with adequate wages Hourly Wages in Louisville Metro, 2008 In trying to make ends meet in the face of low wages and the high costs of living, low income people are forced to make difﬁ cult 1 Adult 1 Adult, 2 2 Adults, 2 Adults, 1 Child Adults 1 Child 2 Children choices in paying for basic needs, including housing, food, transportation, and health care.11 Living Wage $7.93 $15.5 $12.29 $19.9 $26.04 The scope of the problem is demonstrated through the following Poverty $5.04 $6.68 $6.49 $7.81 $9.83 example. The American Community Survey (2009) estimate of Wage the number of people in the Louisville Metro who are employed Minimum in service occupations is 60,983, or 17.8 percent of the population. Wage $7.25 $7.25 $7.25 $7.25 $7.25 The typical hourly wage for a Food Preparation and Service Worker in the Louisville Metro for 2008 was $7.92. Therefore, within one Source: Dr. Amy K. Glasmeier and The Pennsylvania State University industry, approximately 60,000 people in the Louisville Metro could be earning an average wage of just $7.92 an hour, barely a living wage for one adult, much less for a family with children.

Employment Rates 25 Hispanic and black communities in metropolitan areas generally Estimated Unemployment rates in experience greater hardship from unemployment than whites.12 20 Louisville Metro, by Race/Ethnicity, 2005-2009

The single-year ACS estimates for 2009 give an unemployment 15 14.9% estimate for Louisville Metro of 10.4%, higher than the 2009 Louisville Metro KY/IN Metropolitan Statistical Area (MSA) rate 10 of 10.1%.13 The 5-year ACS estimate for 2005-2009 shows the UNEMPLOYMENT RATE 8.6% black unemployment rate at more than double that of whites. This is 5 6.3% believed to be an underestimate because of the way unemployment 3.4% 0 rates are calculated. These rates are based on the proportion of BLACK OR HISPANIC WHITE ASIAN estimated adult workers who are currently receiving unemployment AFRICAN OR LATINO ALONE AMERICAN beneﬁ ts. Because of the extended nature of the recession, the period ALONE of unemployment for many people has exceeded the eligibility period; and these individuals are no longer reﬂ ected in the count.

Unemployment and Health 25 Unemployment is associated with premature death, cardiovascular Self-Reported Poor Health by disease, hypertension, depression, and suicide.14 Evidence shows 20 Employment Status, Ages 18-64 that, even after allowing for other factors, unemployed people and Louisville Metro BRFSS, 2009 their families suffer a substantially increased risk of premature 15 death.15 10 8.5% The chart to the right shows that for BRFSS respondents ages 18-65 POOR HEALTH 5 in Jefferson County in 2009, the rate of poor self reported health for 2.1%

the unemployed was four times higher than the rate for respondents PERCENT OF ADULTS WITH 0 that were employed for wages or self employed. Unemployed Employed for Wages n = 117 or Self Employed n = 568

REPORTING POOR HEALTH

18 LOUISVILLE METRO HEALTH EQUITY REPORT Job Insecurity and Employment and Health Health Beneﬁ ts In the current economy, workers are The United States has a long-standing Health Insurance Coverage increasingly worried that they may be tradition of linking health insurance to by Employment Status in Louisville Metro laid off. Unemployed workers may employment, a relationship that was eventually be forced to take temporary cited recently in the Louisville Health 2009 ACS ESTIMATE employment with agencies that do not Status Report.20 The Institute of Medicine have the workers’ long term interests at (2001) found that families with at least heart.16 one full-time, full-year worker are 86.7% more than twice as likely to have health This sort of insecurity has been shown to insurance coverage, compared to families impact mental health (particularly anxiety whose wage earners work as part-time and depression), self-reported ill health, employees, as temporary workers, or EMPLOYED WITH INSURANCE heart disease and risk factors for heart in which there is no wage earner.21 disease.17 Having little control over one’s Individuals without health insurance work is strongly related to an increased frequently forego timely health care, risk of low back pain, absenteeism, and suffer more severe illness, and are more cardiovascular disease.18 likely to die a premature death than their 49.0% insured counterparts.22 Examining inequities in job insecurity, blacks are more likely than Latinos The 2009 ACS estimates 12.1% of the or whites to work nonstandard hours, population in Louisville Metro (85,000 UNEMPLOYED WITH INSURANCE including rotating shifts, which is people) do not have health insurance associated with greater health risks.19 coverage.23 While high, this is less than the overall KY rate of 16.1%.24

25 Households with Assistance Income support programs With the lack of “good paying” jobs and jobs with 20 Income in Louisville Metro 2009 ACS ESTIMATE suffi cient health benefi ts, people are increasingly 15 12.8% looking to supplement shrinking incomes with income- supporting programs, such as Medicaid, W I C, food 10 stamps, and Section 8 Housing benefi ts. 4.1% 5 2.8%

0 FOOD SUPPLEMENTAL CASH STAMP SECURITY PUBLIC BENEFITS INCOME ASSISTANCE

Income & Employment 19

UNEMPLOYMENT (PERCENT) (Civilian Labor Force, Ages 16 and Older) { 2005-2009 ACS ESTIMATE

22.7% Russell Unemployment is 21.5% California-Parkland associated with premature mortality, cardiovascular 20.2% Algonquin-Park Hill -Park Duvalle disease, hypertension, 20.1% Portland depression, and suicide.+

17.3% Phoenix Hill-Smoketown -Shelby Park Evidence shows that, even 16.2% Chickasaw-Shawnee after allowing for other 15.4% South Central Louisville factors, unemployed people and their families suffer a 11.7% South Louisville Louisville Metro* substantially increased risk 11.5% Shively rate is 7.9% of premature death. ++

10.1% Valley Station *not including Airport Census Tracts Buechel-Newburg 10.0% -Indian Trail 9.9% Fairdale

9.6% Downtown-Old Louisville -University 8.6% Germantown

8.3% Pleasure Ridge Park Downtown- Old Louisville- Phoenix Hill- Smoketown- University 7.6% Butchertown-Clifton Chickasaw- Shelby Park -Crescent Hill Shawnee Northeast Jefferson 6.5% Highview-Okolona Portland Butchertown-Clifton- St. Russell Crescent Hill Matthews 4.9% Fern Creek California- Parkland Highlands Algonquin - Park Hill - 4.8% Southeast Louisville Park Duvalle German- town Southeast J-town South Louisville 4.6% Northeast Jefferson Central Shively Louisville Buechel- 4.5% Floyd's Fork Newburg-- Airport Fern Indian Trail South Creek 4.0% St. Matthews Louisville

Pleasure Ridge Park 4.0% J-town Floyd’s Fork Highview- Okolona 3.6% Highlands Fairdale Valley Station 5

Miles

+ Cornwall, A. & Gaventa, J. (2001). Users and choosers to makers and shapers: Repositioning participation in social policy. Working Paper 127 Sussex. East Sussex, UK: Institute of Development Studies, University of Sussex.

++ Wilkinson, R. & Marmot, M. (Eds.) (2003). Social determinants of health: the solid facts. 2nd edition. Geneva, Switzerland: WHO Press, World Health Organization

20 LOUISVILLE METRO HEALTH EQUITY REPORT

FAMILIES EARNING LESS THAN $15,000 (PERCENT) (Income & Beneﬁ ts in 2009 inﬂ ation adjusted dollars) { 2005-2009 ACS ESTIMATE

44.6% California-Parkland People lower on the 40.4% Russell socioeconomic scale are more + Phoenix Hill-Smoketown likely to experience: 38.8% -Shelby Park • Newborn health problems like Algonquin-Park Hill premature birth, low birth weight, and 33.5% -Park Duvalle birth defects. 32.4% Portland • Signs of future disease like high blood pressure, obesity, weakened 27.5% Downtown-Old Louisville -University immune system.

25.4% South Central Louisville • Chronic diseases like diabetes, heart disease, and many types of 20.0% Chickasaw-Shawnee cancer. Buechel-Newburg 20.0% • Infectious diseases ranging from -Indian Trail HIV/AIDS to the seasonal ﬂ u. 16.5% Germantown • Disabilities like blindness, mental South Louisville illness and decline of physical 13.9% strength.

11.8% Shively

11.0% Fairdale Louisville Metro* rate is 9.8% 9.0% Valley Station *not including Airport Census Tracts 8.4% Butchertown-Clifton Downtown- Old Louisville- Phoenix Hill- -Crescent Hill Smoketown- University Chickasaw- Shelby Park 8.1% Pleasure Ridge Park Shawnee Northeast Jefferson Portland 7.2% Highview-Okolona Butchertown-Clifton- St. Russell Crescent Hill Matthews 5.4% St. Matthews California- Parkland Highlands Algonquin - Park Hill - Park Duvalle German- 5.0% Southeast Louisville town Southeast J-town South Louisville Central 3.9% Highlands Shively Louisville Buechel- 3.3% Fern Creek Newburg-- Airport Fern Indian Trail South Creek 3.1% J-town Louisville Pleasure Ridge Park Floyd’s Fork 2.5% Northeast Jefferson Highview- Okolona 2.3% Floyd's Fork Fairdale Valley Station 5

Miles

+Adler, N. & Stewart, J. (2008). Reaching for a healthier life: Facts on socioeconomic status and health in the U.S. The John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health.

Income & Employment 21 HOUSING Housing is a dynamic, multi-faceted housing (the links between poor health, and have higher rates of specifi c issue. In this brief overview of the ways housing conditions and a range of chronic health conditions in comparison in which housing can contribute to health preventable and chronic diseases are to similar people living in affordable or disease, the following factors are addressed more fully in the section on housing.6 considered: Environment and Health on page 32). When looking specifi cally at renters, • Housing Affordability • Lose out on the opportunity for “wealth research shows signifi cant associations • Home Ownership accumulation” that has traditionally between unaffordable rent, and • Foreclosures come from homeownership; or inadequate childhood nutrition and • Fair Lending they can risk a fi nancial crisis and growth.7 Higher rents, especially for low- • Housing Segregation bankruptcy when they are over- income families, drastically reduce the • Subsidized Housing and Housing extended. Wealth accumulation income that a family can devote to other associated with homeownership Supports basic needs, including food, clothing, improves access to neighborhoods • Housing Instability and Residential medicine, health care and family with more health promoting assets, Displacement activities that help provide exercise and such as grocery stores, places to 8 • Homelessness emotional stability. exercise, and good schools, as well as 2 In low-income neighborhoods and to higher quality housing. communities of color, adverse housing • Are at risk for a myriad of poor health factors are disproportionately present outcomes associated with the impact Fair Market Monthly Rents for and their cumulative effect can take a of accumulated stress. Financial Louisville Metro serious toll on the health of their citizens. strain related to housing is linked with FY 2001 - FY 2011 $1200 poor health outcomes including all- Housing & Health cause mortality, a higher prevalence 4 BEDROOM Housing can be a determinant of the $1000 of chronic conditions, and a higher health of individuals, families, and 3 BEDROOM incidence of depressive symptoms.3 the communities in which they live. $800 Health is not only affected by the 2 BEDROOM 1 BEDROOM physical characteristics of housing $600 Housing Affordability & units and neighborhood design, but it Health 0 BEDROOM is deeply impacted by the social and High housing-related costs lead to health $400 economic factors that underlie housing risks in a variety of ways, with families statistics, such as neighborhood stability having to make tough decisions between 20012002 2003 2004 2005 2006 2007 2008 2009 2010 2011 and the building of wealth through housing costs and health insurance, homeownership. Housing not only To afford Fair Market Rent (2010) for a 2 Bed medications, and healthy foods.4 provides basic shelter, it can determine Room unit in Louisville, a household needs an annual income of $27,360 where people shop, go to school, play, The stress experienced as a result of and work, and it can infl uence who their unaffordable housing is associated 46% of Renters in Louisville are unable to afford the Fair Market Rate for 2 Bed Room friends are and the opportunities they with a increased risk for developing 1 housing unit have to be an active part of a community. hypertension, lower levels of psychological well-being, and more Source: U.S. Department of Housing and Urban Development Families that have diffi culty affording *data for years 2001 and 2002 are for the Louisville, KY/IN MSA visits to the doctor.5 housing:

• Often live in neighborhoods of For both homeowners and renters, disinvestment with more risk factors, those living in unaffordable housing are including larger stocks of substandard more likely to report cost-related health care nonadherence, poor self-reported

22 LOUISVILLE METRO HEALTH EQUITY REPORT Homeownership and Health 100% Percent of Homeowners by Race/Ethnicity Historically, homeownership has been the 2007-2009 ACS ESTIMATES primary, long-term strategy for building LOUISVILLE/JEFFERSON COUNTY wealth in the United States, and wealth UNITED STATES is one of the strongest determinants of 75% 74.8 health.9 But many families continue 72.4 to deal with obstacles to accessing and 59.3 50% maintaining homeownership, including 51.2 the ever-increasing cost in utilities, health 48.4 46.2 care, food, and other necessities and the 40.6 39.5 impact of ﬂ at or declining income.10 25%

Nationally, homeownership rates have dropped to their lowest levels since 1998, 0% and homeownership rates for Hispanics WHITE ASIAN HISPANIC BLACK OR ALONE OR LATINO AFRICAN and African Americans have dropped AMERICAN 11 nearly twice as much as for whites. ALONE This represents a massive drain of wealth from Latino and African American stability in these communities brought on borrower losses due to foreclosure communities, who were starting with by foreclosures present an acute public nationally represent 46% of total losses homeownership rates some 25 points health crisis.15 to foreclosure, even as these two groups lower than whites. This disparate drop in represent only 27.9% of the population homeownership exacerbates the growing Many of the neighborhoods impacted by of the United States. The loss of wealth racial wealth gap.12 high foreclosure rates already bear the among African American and Latino sub burden of the poorest health outcomes, prime borrowers due to foreclosure is A reduction in homeownership has with the life expectancy in these areas estimated at $213.1 billion, compared also been linked to a reduction in local being up to 10 years less than other areas to a loss of $462.2 billion for sub prime businesses, which not only affects the of the city.16 In a recent study conducted borrowers as a whole.18 goods and services that are available, but on foreclosures in Louisville, 50% of also affects the employment opportunities the foreclosure study participants cited for local residents. The ripple effect medical expenses or health issues as a continues in that the loss of jobs can, in primary

! factor ! ! ! ! turn, lead to increased foreclosures, and ! ! ! ! ! ! Foreclosure Auctions, 2009 ! ! ! ! ! 13 ! ! leading to the ! ! ! general disinvestment. ! ! !! ! !! !!! ! ! ! ! ! !! !! ! One Foreclosure Auction ! ! ! ! ! ! ! ! 17 !!! ! ! ! !! ! ! ! !!! ! !! ! ! ! !!! foreclosure. ! ! ! ! ! ! !!! !! ! ! ! ! ! ! ! ! ! !!!! !!! ! ! ! ! ! ! ! ! ! ! ! ! ! !! ! !! !! !! ! ! ! !! ! !!! ! !! ! ! ! ! !!! ! ! !! ! !! ! ! ! !! ! !!!!!! ! !! !! ! !!!!!!!!! !!!!!! ! ! ! ! !! ! ! !!! !!! !!!!!!!!!! !! ! ! ! ! ! !!!!! !!! !!! !!!! ! ! ! ! !!!! ! ! !! ! !! !!!!!!! ! !!! !!! !! ! !! ! ! ! ! ! !! ! ! !! ! !!!! ! !!!!!! !!!!!! ! ! !! ! ! ! ! ! ! !! !!! !!!! ! !!!!! ! ! !! ! ! ! ! ! ! ! At the root ! ! !!!! ! !!!!!!!!!!! ! !! ! ! ! ! ! ! !!!!! !! !!! !!!! ! ! ! ! ! ! ! ! ! !!!!!!!!! !!!!!!!! !! ! ! ! ! ! ! ! ! ! !! !!!!!!!!!!!!! ! ! !!!! ! ! ! ! ! !! !! ! ! ! ! ! ! ! Foreclosures !! !! !!!!!!!!! !!!!!!! ! !! ! !! ! ! ! ! ! ! ! ! ! ! !! !! ! ! !!!!! !!! ! ! !! ! ! ! ! ! ! ! ! ! ! ! ! !! !! !! ! ! ! ! ! !! ! ! ! ! ! !!!! !!! !!!! !! ! ! ! ! ! !!!! !! !!!!!!!!! ! ! !! ! ! ! ! ! ! ! ! ! !! !!!!!! !!!!! !! ! ! !! !!! ! ! ! ! ! !!!!! !!!!! !!!!!!!!! ! ! !!!!!!!!! !!!! !!! ! ! ! ! ! ! ! ! ! !!!!!!!! !! !!!!!!!!! !!! ! ! ! ! ! !! of many !!!!!!!!! !!!! !! ! !! !! !!!! ! ! ! ! ! ! ! ! !! ! ! ! !!! ! ! ! ! ! !!! ! !!!!!!!!! ! ! ! !! !!! !!!! ! !! !!!! ! ! !! ! ! ! Foreclosures can have devastating health !!!!!!!!!! !!! !!!!!!!!!! ! ! !! ! ! !! ! ! ! !! ! !! ! !!! !!!! !!! ! ! ! ! ! ! ! ! !!!!!!!!!! !! !! !! !! !! !!! ! ! !! ! ! ! !!!! !!! !! !! !!!! ! ! ! ! !!!! !!!!!!! ! !! !! !! !! ! ! ! ! ! ! ! !! !!! !!!! !!! !!! !! !! !! ! ! ! ! !! !! !! !! ! ! ! ! ! ! ! ! !!! !! !! ! ! ! ! ! ! ! !! ! ! ! ! !! !!!! ! !! ! ! ! !! ! ! ! ! ! ! !!! !!! ! ! ! ! !!! !! ! ! foreclosures !! !!! !!!! !!!! ! ! ! ! !! ! !! ! ! ! ! ! !! ! ! ! ! ! ! !! ! !!! !!! ! ! ! ! ! !! ! !!! !! ! impacts, not only for individuals and ! ! ! !! ! ! !!! !! !! ! !! ! ! !! ! ! ! ! ! ! ! ! !! ! !! !!!! ! !! ! ! ! ! ! !! ! ! !! ! !!! ! ! ! !!! ! ! ! ! ! !! ! ! !!! ! ! ! ! !! ! ! !!!! !!!!! !! ! ! !! ! ! !! ! ! ! ! ! !!! ! ! ! !!!! ! ! ! ! ! ! !! ! ! ! ! ! !! !!! ! !!!!!! !! !!! ! !!! ! ! ! !! ! ! ! ! !!! !!!!! ! ! !!!!!!! !!!!! !!! ! !! ! ! ! !!! !! !! ! !!!! !!!!! !!!!! ! !!! !!! !!! ! ! ! ! ! !!!! ! ! !!!! ! ! !! ! ! ! ! ! ! ! !!! !! ! ! ! !!! ! ! !!!!! ! !! !!! ! !!!! ! ! !! ! ! !! ! !! ! ! are high cost ! !! !! ! ! ! ! !!!!!!!!!! ! ! ! ! ! !! ! ! !! !! ! ! ! ! ! ! ! ! !! !! ! ! ! ! ! ! !! ! !!! ! !!!!!! ! ! ! ! !!!!!!! !!! ! ! ! families undergoing severe stress and loss ! !!!!! ! ! !!!!! !!! !! !!!! ! !! !! ! ! ! ! ! ! ! ! !!!!! !! !!!!! ! !! ! ! ! !! !!! ! ! !! ! ! !! ! ! ! ! !! ! ! ! ! !!!! ! ! !!! !!! ! ! ! !! !! !! ! !! ! ! ! ! !! ! ! ! !! ! ! ! !!!! !! !! ! ! ! ! ! ! ! ! ! ! !! ! ! ! !! ! !! !!!! ! ! !! ! ! !!! ! ! !! ! !! ! ! !!! ! ! !!! !!! !!! ! ! !!!!! !! !! ! !!! !! ! !!! ! ! !!! ! !! ! !!!!! ! ! !! !!! ! !! !! !! !! ! ! ! ! ! !! ! !! !!! ! ! !! ! ! ! ! !! !! !! ! !!! ! ! ! ! ! ! ! ! !!! ! ! ! !! !! !!!! ! ! ! loans and !!! !!! !! ! !! !! !! !!!! ! !!! !! ! ! ! ! ! ! ! ! ! !!! !!!! !! !! ! !! ! ! ! ! !!! !! ! ! ! ! of wealth from the process, but also for !!!!!!!! ! ! ! !!! !! ! ! !!!!! ! !!!!!!! ! !!! ! ! !!! !!! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !! ! !! ! ! !!! !!! !! ! ! ! ! ! !!! ! ! ! !! ! ! ! !!!! ! ! !! ! ! ! ! ! ! ! ! !! !! ! ! ! ! !! ! ! ! !! ! ! ! ! !! ! !!!! ! ! ! ! ! ! ! ! !! ! !! ! !! ! ! ! ! ! ! !! ! ! ! ! !! !! ! ! ! ! ! ! !! ! ! ! !! !!! ! ! ! ! ! ! the practice !! !!!!! !! ! !! ! ! !!!! ! !! ! ! ! !! ! !!!! ! !! ! ! !! ! !! ! ! ! ! !! ! ! ! ! ! !! !! !! ! ! !!! !!!! ! ! !!! !! ! entire neighborhoods that experience the ! ! ! ! ! ! ! !! ! !! ! !!! ! ! ! !! ! !! ! ! ! ! ! ! !! ! ! ! ! !!! ! ! ! ! ! ! ! !!!!! !!! ! !! ! ! ! !! !!!! ! ! ! ! ! ! ! ! ! ! ! !! ! !!!! ! ! ! ! ! ! ! ! ! !!! ! !!!! ! ! ! !! ! ! ! ! ! !!!! ! ! ! !! !! !! !!! ! !! ! ! ! ! !! !! !!! !! ! !! ! ! !! !! ! ! ! ! ! ! !! !! ! ! ! ! ! !!!! !! ! ! !!! ! !! ! ! ! ! !! !! ! ! ! !! !! ! ! of sub prime ! ! ! ! ! ! ! !!! ! ! ! ! ! ! !!!! !! !! ! ! !! ! !!!! ! effects of intensiﬁ ed disinvestment. Homes !! !!! !! ! ! !!! ! !! !! ! !!! ! ! ! ! !! !! !!! ! ! ! ! !! ! ! ! ! ! !! ! ! ! !! ! ! !! !!! ! ! ! ! ! !! ! ! !! !!! ! ! ! !!! ! ! ! ! ! !! !!! ! ! ! !! ! !!!!! ! ! ! ! !! ! ! !! ! !!! ! !! ! ! ! ! !!! ! ! !! !!!!!!!! !! ! ! ! !!!! ! !! ! ! ! ! ! !!! ! !! !!! !!! !!!! ! ! ! ! !! !! ! ! lending. ! !! !! ! ! ! !! ! ! ! !! ! ! ! ! ! ! ! ! ! ! ! !! ! ! ! ! sold through foreclosure auctions at a ! ! !! !!! ! !! ! ! !! ! ! !!!!! !! !! ! !!! ! ! ! ! ! ! !! ! ! ! ! !! !!! ! !! !! ! ! ! !! !!!!! ! ! ! !! ! ! ! ! !! ! ! ! ! !!! ! ! !! ! !!! ! ! !! ! ! ! ! ! ! ! !! !!!! ! ! African ! !!! ! ! ! considerable discount will further depress !! !

! !! !!!!! ! ! !!!!!!!! ! ! ! American !!!! ! ! ! values of surrounding properties, directly !!!! ! ! !! 5 !!! impacting the quality of the community.14 and Latino Miles ! Combined, the loss of health, wealth, and sub prime Data Source: Jefferson Circuit Court Commissioner’s Ofﬁ ce

Housing 23 Housing Segregation individual attitudes of people wanting Home Purchase Loans Denied by Living in racially segregated neighbors with similar characteristics, Race/Ethnicity and Income, neighborhoods has been associated such as race, color or religion; Louisville KY/IN MSA 2009 with higher rates of infant mortality, however, extensive studies confi rm LESS THAN 50% OF MEDIAN INCOME that in many cases people with low overall mortality, violent crime, chronic BLACK OR 28.3% AFRICAN AMERICAN disease, and higher risk for transmission incomes live together not through WHITE ALONE 23.0% of infectious diseases such as mechanisms of “self-segregation”, but ASIAN 17.1% 19 rather by not having any other choice.21 tuberculosis. A signifi cant contributor HISPANIC OR LATINO 14.6% to these conditions is the poverty that Since housing choice is directly related exists in many of these neighborhoods. to housing affordability, families live in 50% - 99% OF MEDIAN INCOME Poverty is exacerbated by diminished areas with the most affordable options, BLACK OR 21.7% opportunities for accruing wealth even if that means living in an area that AFRICAN AMERICAN 13.5% through homeownership in a safe is harmful to health. WHITE ALONE 18.3% and desirable neighborhood and the ASIAN HISPANIC OR LATINO 11.1% discriminatory practices of unfair lending practices. Research has shown Fair Lending that African American homeowners The stress related to high cost 100% OR MORE OF MEDIAN INCOME BLACK OR 22.3% accumulate less equity in their homes loans, mortgage debt, and insecure AFRICAN AMERICAN because they often own homes in homeownership is associated with WHITE ALONE 9.4% segregated neighborhoods.20 a greater likelihood of developing ASIAN 9.8% hypertension, lower levels of HISPANIC OR LATINO 16.7% Some segregation can be linked to psychological well-being, and increased visits to the doctor.22 Louisville was ranked as the displacement affects community health. 26th most segregated of 150 Latinos and African Americans receive When people lose their homes, or high costs loans at a higher rate than metropolitan areas according are threatened by losing their homes, whites, regardless of income. A study to an analysis of the 2000 they experience high levels of stress conducted in 2009 found that Latinos Census by the University of and emotional strain. The impact of and African Americans received high- Louisville. Forty-fi ve percent this loss can be exacerbated given the cost loans at a rate two to three times person’s emotional attachment to their of Louisville residents live in 23 that of whites. Among borrowers home.25 extreme racial segregation, with the highest FICO (Fair Isaac despite Louisville’s increase Corporation) scores (>720), 13.5% of Displacement not only means a in racial and ethnic diversity Latino and 12.8% of African Americans disruption in one’s living situation, in recent decades - these received high-cost loans, compared to but it can result in loss of job, diffi cult factors have contributed to 2.6% of white borrowers with FICO school transitions, and the loss of decreasing homeownership scores above 720.24 health protective social networks.26 rates for African-Americans Displacement can be extremely diffi cult on all members of a family and people in Louisville, during a period Housing Instability of all ages. Research has shown that when the homeownership 27 and Residential it can affect child development. A rates have increased for longitudinal study of the impact of Displacement African Americans in most residential stability on health outcomes Whether it involves homeowners other metropolitan areas in found that residential stability at struggling to maintain their homes the country. childhood (as measured by moving during foreclosures, or families 0-2 times) increases the odds that relocating as public housing is torn Metropolitan Housing Coalition, 2010 an individual will have better health down, housing instability and residential outcomes later in life.28

24 LOUISVILLE METRO HEALTH EQUITY REPORT

FORECLOSURE RATE (Estimated Foreclosure Starts/Estimated Number of Mortgages) { 2007- June 2008 - HUD

10.8% California-Parkland Many of the neighborhoods Russell 10.3% impacted by high foreclosure 9.5% Chickasaw-Shawnee rates already bear the burden of the poorest health 9.3% Portland outcomes, with the life Algonquin-Park Hill 9.2% expectancy in these areas -Park Duvalle being up to 10 years less 8.5% South Central Louisville than other areas of the city.+ 8.3% Shively In a recent study conducted 7.6% Buechel-Newburg -Indian Trail on foreclosures in Louisville, 6.1% Valley Station 50% of the foreclosure study participants cited medical 6.0% Fairdale expenses or health issues 5.7% Phoenix Hill-Smoketown -Shelby Park as a primary factor leading to the foreclosure action 5.5% Pleasure Ridge Park against them.++ 5.1% South Louisville

5.1% Highview-Okolona Louisville Metro* rate is 4.2% 4.1% Fern Creek *not including Airport Census Tracts

4.0% Germantown Downtown- Old Louisville- Phoenix Hill- Smoketown- Downtown-Old Louisville University 3.6% Chickasaw- Shelby Park -University Shawnee Northeast Jefferson 3.2% Southeast Louisville Portland Butchertown-Clifton- St. Crescent Hill J-town Russell Matthews 3.0% California- Parkland Highlands Butchertown-Clifton Algonquin - Park Hill - 2.9% Park Duvalle German- -Crescent Hill town Southeast J-town South Louisville 2.8% Floyd's Fork Central Shively Louisville 2.4% Northeast Jefferson Buechel- Newburg-- Airport Fern Indian Trail South Creek 2.2% St. Matthews Louisville

Pleasure Ridge Park 1.9% Highlands Floyd’s Fork Highview- Okolona

Fairdale Valley Station 5

Miles

+ Just Cause and Alameda County Public Health Department. (2010). Rebuilding neighborhoods, restoring health: A report on the impact of foreclosures on public health. Oakland, CA.

++Metropolitan Housing Coalition. (2008). Housing insecurity: Neighborhood conversations on health care costs. Louisville, KY.

Housing 25

PERCENTAGE OF HOUSEHOLDS PAYING 35% OR MORE OF INCOME FOR RENT { 2005-2009 ACS ESTIMATE

54.5% Portland High housing-related 53.5% Chickasaw-Shawnee costs lead to health risks + 53.2% Algonquin-Park Hill in a variety of ways: -Park Duvalle 50.7% South Central Louisville • Such as when families have to make tough decisions between 49.6% Valley Station housing costs and paying 49.6% Shively health insurance, medications, and healthy foods; 49.2% California-Parkland • Through the potential Downtown-Old Louisville 45.1% -University association with housing quality and neighborhood features; 42.8% South Louisville and, 42.2% Russell • As an indicator for low 41.3% Phoenix Hill-Smoketown socioeconomic status -Shelby Park associated with material 41.2% Louisville Metro* Pleasure Ridge Park deprivation and housing rate is 39.3% 38.3% Highview-Okolona instability *not including Airport Census Tracts Buechel-Newburg 38.0% -Indian Trail 37.5% Germantown Butchertown-Clifton 36.3% Downtown- -Crescent Hill Old Louisville- Phoenix Hill- Smoketown- University 35.6% St. Matthews Chickasaw- Shelby Park Shawnee Northeast Jefferson 34.4% Southeast Louisville Portland Butchertown-Clifton- St. Crescent Hill Fairdale Russell Matthews 34.4% California- Parkland Highlands Algonquin - Park Hill - Park Duvalle German- 32.3% Northeast Jefferson town Southeast J-town South Louisville 29.8% Fern Creek Central Shively Louisville Buechel- 29.0% Floyd's Fork Newburg-- Airport Fern Indian Trail South Creek 28.3% J-town Louisville

Pleasure Ridge Park 26.9% Highlands Floyd’s Fork Highview- Okolona

Fairdale Valley Station 5

Miles

+ Pollack, C., Grifﬁ n, B., & Lynch, J. (2010). Housing affordability and health among homeowners and renters. American Journal of Preventive Medicine, 39(6), 515-521.

26 LOUISVILLE METRO HEALTH EQUITY REPORT ENVIRONMENTAL QUALITY Indoor Environmental allergies.5 Materials used for building or vehicles. Together they contribute a huge Quality & Health for pest control can be additional sources amount to pollution in the air.11 The impact on health of having access to of danger: pesticide residues can cause safe, affordable housing was addressed in neurological disorders, and pressure- Exposure to traffi c-related pollution is a previous section. However, the internal treated wood can contain dangerous associated with health problems including environment within a home can also carcinogens.6 asthma, reduced lung function, certain create threats to health. These threats types of cancers, cardiopulmonary and can come in the form of hazardous While not all old housing is dangerous, stroke mortality, and premature births.12 substances used in the building of the large stocks of older housing in Particulate matter from cars and trucks home. For example, Asbestos in older disinvested neighborhoods are likely to creates higher rates of cardiovascular homes can cause lung cancer, asbestosis, contain many of the physical features disease and asthma, leading to hospital and mesothelioma1; and, lead paint, associated with substandard housing. visits and premature death.13 More also found in older homes, can be a For example, areas in Louisville with specifi cally, research has shown that serious risk to the health of children and high concentrations of poverty and living within 1000 feet of high traffi c pregnant women. Health implications communities of color have much of the roads (measured by some as 100,000 for children exposed to lead paint include housing built before 1950; however, it vehicles a day) leads to measurably higher an increased risk for asthma, learning was not until the 1970s that the ban on non-cancer health risks.14 On a typical disabilities, seizures, and lead poisoning.2 lead in paint took effect.7 In an analysis urban freeway with large truck traffi c of of housing conditions and other risk 10,000-20,000 a day, particulate matter Health threats can also be caused by a factors related to health, Louisville’s from diesel represents about 70 percent of deterioration of the home’s structure Metropolitan Housing Coalition found the potential cancer risk from the vehicle or an infestation of pests within the that problems related to poor indoor traffi c. Diesel particulate emissions structure. Furthermore, the ability air quality were highly concentrated in are of particular concern as research to control the climate in the living northwest and southwest portions of demonstrates an association between unit is compromised when doors and Metro Louisville.8 particulate matter and premature mortality windows do not fi t properly; and, in those with existing cardiovascular improperly winterized homes can Outdoor Environmental disease.15 lead to the secondary use of improper Quality & Health heating devices. Improperly installed Air pollutants are causal factors for or poor quality heating devices have increased rates of mortality, disease and caused respiratory ailments and even illness.9 Airborne pollutants can cause 3 death. Exposure to rain or other forms increased sickness and premature death of moisture caused by a leaky roof from asthma; bronchitis; emphysema; or internal pipe can compromise the pneumonia; and cardiovascular disease, home’s internal environment by causing including coronary artery disease, mold and mildew. These biological abnormal heart rhythms, and congestive contaminants can lead to respiratory heart failure.10 Air pollution comes from diseases such as asthma or allergic a variety of sources: both stationary and 4 symptoms. mobile. The stationary sources stem from industrial uses and utilities, and Homes that are open to the elements are include steam production, process boilers, vulnerable to pest infestation and mold coal fi re, and other forms of electricity and mildew; both of which can cause generation. Mobile sources include the respiratory diseases such as asthma or emissions from cars, trucks, and other

Environmental Quality 27 Louisville has a number of high trafﬁ c volume highways. Respiratory Risk from Three interstate highways traverse Jefferson County and they On-Road Pollution Source, converge in downtown Louisville. EPA 2002 The high number of industrial, chemical, and manufacturing plants in the county can also contribute to poor environmental quality. Two recent studies point to the particular problem in Louisville’s poor and minority communities.

• A study of air toxins conducted in 2000-2001 found that chronic risk levels from outdoor air pollution were higher in every West Louisville testing site.16

• In a 2009 nationwide study, looking at the largest discrepancies between the percentage of minorities at 5 risk of poor health outcomes from industrial air toxins and Miles their percentage of the population, Louisville, KY-IN MSA Hazard Quotient The ratio of the potential exposure to 1.3 - 2.1 was ranked sixth from the top. In the MSA encompassing the substance and the level at which 2.2 - 2.7 Louisville Metro and Southern Indiana, minorities account for no adverse effects are expected. If the 37% of the health risk while making up only 18% of the total Hazard Quotient is calculated to be 2.8 - 3.5 less than 1, then no adverse health population.17 3.6 - 5.0 effects are expected as a result of exposure. If the Hazard Quotient is greater than 1, then adverse health In addition to air pollutants, low-income persons, racial and ethnic effects are possible minorities, children, the elderly, and those with disabilities suffer disproportionately from environmental pollutants in the soil and ground water near low income neighborhoods.18 Undesirable land uses such as power plants and factories are often situated in Total Respiratory Risk low-income neighborhoods.19 The most polluted locations often from All Sources, have signiﬁ cantly higher-than-average percentages of blacks, EPA 2002 Latinos, and Asian-American residents.20

Abandoned industrial sites, known as brownfi elds (which may be contaminated) can be a burden for communities with low levels of investment.21 Brownfi elds can provide environmental hazards in any of several domains. As described by the EPA, brownfi elds can be the source of the following risks:22

• Safety – abandoned and derelict structures, open foundations, other infrastructure or equipment that may be compromised due to lack of maintenance, vandalism or deterioration, controlled substance contaminated sites (i.e., 5 methamphetamine labs) and abandoned mine sites; Miles Hazard Quotient 1.8 - 3.0 • Social & Economic – blight, crime and vagrancy, reduced The ratio of the potential exposure to social capital or community ‘connectedness’, reductions in the substance and the level at which 3.1 - 3.8 no adverse effects are expected. If the local government tax base and private property values 3.9 - 4.9 the Hazard Quotient is calculated that may reduce social services; and, to be less than 1, then no adverse 5.0 - 7.9 health effects are expected as a • Environmental – biological, physical and chemical from result of exposure. If the Hazard site contamination, groundwater impacts, surface runoff or Quotient is greater than 1, then adverse health effects are possible migration of contaminants as well as wastes dumped on site.

28 LOUISVILLE METRO HEALTH EQUITY REPORT ON-SITE TOXIC RELEASES FROM FACILITIES (Total On-Site Disposal or Other Releases in Pounds) EPA TOXIC RELEASE INVENTORY 2009

Valley Station 5,646,717

Pleasure Ridge Park 1,489,107

1,417,704 Shively TECHNICAL NOTE: On-site disposal or other releases include emissions to the air, discharges Northeast Jefferson 296,059 to bodies of water, disposal at the facility to land, and disposal in Airport 188,928 underground injection wells.

South Louisville 172,215 Toxic Relief Inventory (TRI) data reﬂ ect releases and other waste management activities of chemicals, not whether (or to what degree) the Buechel-Newburg 119,145 public has been exposed to those chemicals. Release estimates alone -Indian Trail are not sufﬁ cient to determine exposure or to calculate potential adverse Downtown-Old Louisville 56,148 effects on human health and the environment. TRI data, in conjunction with -University other information, can be used as a starting point in evaluating exposures 35,737 California-Parkland that may result from releases and other waste management activities 25,434 which involve toxic chemicals. The determination of potential risk depends Highview-Okolona upon many factors, including the toxicity of the chemical, the fate of the Algonquin-Park Hill 11,889 chemical, and the amount and duration of human or other exposure to the -Park Duvalle chemical after it is released. Phoenix Hill-Smoketown 4,726 -Shelby Park Russell 2,495

J-town 705

South Central Louisville 5 Butchertown-Clifton Downtown- Old Louisville- Phoenix Hill- 0 Smoketown- -Crescent Hill University Chickasaw- Shelby Park Shawnee Northeast Chickasaw-Shawnee 0 Jefferson Portland Fairdale 0 Butchertown-Clifton- St. Russell Crescent Hill Matthews California- Fern Creek 0 Parkland Highlands Algonquin - Park Hill - Park Duvalle German- town Floyd's Fork 0 Southeast J-town South Louisville Shively Central Germantown 0 Louisville Buechel- Airport Newburg- Highlands 0 Indian Trail Fern South Creek Louisville Portland 0 Pleasure Ridge Park Floyd’s Fork Highview- Southeast Louisville 0 Okolona

St. Matthews 0 Fairdale Valley Station 5

Miles

Environmental Quality 29

PRE 1950’s HOUSING (Percentage of Older Houing Stock per Neighborhood Area) 2005-2009 ACS ESTIMATE {

75.9% Portland

75.6% Germantown Areas in Louisville with high 71.0% California-Parkland concentrations of poverty and communities of color 69.3% Highlands have much of the housing built before 1950; and, it 67.3% Chickasaw-Shawnee was not until 1950 that the Downtown-Old Louisville ﬁ rst regulations limiting lead 64.0% -University appeared nationally.+ Phoenix Hill-Smoketown 60.9% -Shelby Park In an analysis of housing 57.8% Russell conditions and other risk factors related to health, Algonquin-Park Hill 52.0% -Park Duvalle Louisville’s Metropolitan Butchertown-Clifton Housing Coalition found that 50.1% -Crescent Hill problems related to poor indoor air quality were highly 49.2% South Central Louisville concentrated in northwest and 26.2% Southeast Louisville southwest portions of Metro Louisville.+ + 24.6% South Louisville Louisville Metro* rate is 23.7% 23.3% St. Matthews *not including Airport Census Tracts 16.0% Shively Downtown- Old Louisville- Phoenix Hill- Smoketown- Fairdale University 14.3% Chickasaw- Shelby Park Shawnee Northeast Buechel-Newburg Jefferson 8.4% -Indian Trail Portland Butchertown-Clifton- St. 8.4% Pleasure Ridge Park Russell Crescent Hill Matthews California- Parkland Highlands 5.8% Valley Station Algonquin - Park Hill - Park Duvalle German- town Southeast J-town 4.8% Northeast Jefferson South Louisville Central Shively Louisville 4.7% Floyd's Fork Buechel- Newburg-- Airport Fern Indian Trail 3.1% J-town South Creek Louisville

3.1% Highview-Okolona Pleasure Ridge Park Floyd’s Fork Highview- 2.6% Fern Creek Okolona

Fairdale Valley Station 5

Miles

+ Metropolitan Housing Coalition. (2010). The state of fair housing in Louisville: Impediments and improvements. Louisville, KY. + + Ibid

30 LOUISVILLE METRO HEALTH EQUITY REPORT EDUCATION Education and Health Inequalities in education and income are at People Ages 25-65 Reporting ‘Good’ the root of many health disparities in the or ‘Excellent’ Health, by Education Level* U.S. The population groups that suffer the Louisville Metro BRFSS, 2009 worst health status also are those that have 100 College Grad Some or More College the highest rates of poverty and the lowest 80 High School/GED levels of education.1 For people ages 25- No High 83.8% 60 75.2% 64, the overall death rate for those with less School 68.8% 40 than a high school education is more than 41.5% twice that for people with 13 or more years 20 of education.2 0

*Respondents with higher ediucation levels are more likely to report ‘Good’ or ‘Excellent’ health While income levels are an important x2 = 58.9, df = 3, p-value = 0.0000001 determinant, research has shown that independent of income, education level is illustrates the link between educational associated with improved health outcomes Higher levels of inequality between level and healthy behaviors. Nineteen and -- each additional year in school is rich and poor in a society correlate with a half percent (19.5%) of adults in the associated with increased life expectancy.3 increased mortality among occupants of Louisville Metro who have a college degree the lower economic segment.7 Lack of a report eating three or more vegetables a An individual’s health is highly correlated high school education accounts for much day; while fewer than ﬁ ve percent (4.3 %) with success in school, and the number of of this income inequality effect and is a of Louisville Metro adults without a high years spent in school are major factors in powerful predictor of mortality variation school degree report eating three or more 8 11 determining social and occupational status among U.S. states. vegetables a day. Similar trends are noted in adulthood.4 for physical health and smoking. Education & Risk Behavior ““EducationEducation isis a strongstrong Education, Health and Lower levels of education are connected to increased health risk behaviors such as ppredictorredictor ofof long-termlong-term Wealth smoking, being overweight or engaging in hhealthealth andand qualityquality ofof Educational attainment is one of the llife”ife” minimal physical activity.9 Higher levels strongest predictors of income, and income of education are associated with better is directly related to our health.5 Education health decision making.10 indirectly impacts health through enhanced access to necessary resources (e.g., health Persons with high levels of education care). Further, as incomes rise, people are also display healthier eating habits. The more willing and able to pay for health care most recent data from the Behavioral and preventive health care.6 Risk Factors Surveillance Survey (2009)

LLowow andand LowLow , 22006006

People Ages 25-65 Reporting Risk Behaviors, Louisville Metro BRFSS, 2009 NOT EATING 3 OR MORE SMOKE NO PHYSICAL ACTIVITY VEGETABLES DAILY* EVERYDAY** OUTSIDE OF WORK*** NO HS DIPLOMA 95.7% 52.0% 33.1% HIGH SCHOOL/GED 94.3% 43.9% 21.6% SOME COLLEGE 90.3% 40.0% 15.2% COLLEGE OR MORE 81.5% 20.4% 11% *Respondents with more education are more **Respondents with more education ***Respondents with more education likely to eat 3 or more vegetables daily are less likely to smoke more likely to exercise x2 = 24.6, df = 3, p-value = 0.00002 x2 = 32.6, df = 3, p-value = 0.0000004 x2 = 32.95, df = 3, p-value = 0.0000003

Education 31 Education & Chronic Parental Education Dropping out of High Conditions Level School In a recent CDC survey, Louisville There is a powerful connection between Health factors often drive the decision respondents ages 25-65 with less than a infant and child health and level of to leave school early. Pregnancy, family 12 illness and chronic conditions (e.g., high school education were more likely to maternal education. The impact seems asthma, learning disability or physical to begin in the womb, as numerous have been diagnosed with diabetes, stroke, disability) are all examples of health studies have found strong correlations heart disease, and asthma compared to related reasons for withdrawing.20 between educational attainment of the respondents with a college degree. 13 mother and birth outcomes. Mother’s Dropping out of school can lead to limited education is an important predictor of the employment opportunities, poverty, and People Ages 25-65 Reporting health of children even after controlling poor health, and is also associated with Chronic Conditions for income, health environments, and adolescent substance abuse, delinquency, 21 Louisville Metro BRFSS, 2009 other socioeconomic variables.14 injury, and pregnancy.

NO HIGH SCHOOL Adolescents living in high poverty HIGH SCHOOL/GED The education level of parents has also SOME COLLEGE neighborhoods often have lower level been shown to affect levels of obesity. COLLEGE OR MORE of educational achievement and a higher In one study, parental education level risk of dropping out of school.22 ASTHMA* *Signiﬁ cant differences was the strongest predictor of children’s among groups 27.1% (x2 = 7.6, df = 3, obesity and children of the lowest social p-value = 0.05) status had more than three times the Birth Outcomes by Mother’s Education Level, 20.6% risk of being obese than children of the 2008-2009 17.0% 15 16.5% highest social status. Jefferson County Vital Statistics

NO HIGH SCHOOL HIGH SCHOOL/GED High Quality Child Care SOME COLLEGE Research has demonstrated the COLLEGE OR MORE signifi cance of early childhood Low Birth Weight development as a foundation for long- 11.8% DIABETES** **Signifi cant differences 16 10.8% among groups term health and well-being. The ability 10.0% 24.6% Signifi cant (x2 = 17.2, df = 3, p-value = 0.0006) to succeed in school and later in life 7.2% differences among groups 19.0% is heavily infl uenced by factors that 2 = 17.3% (x 74.9, are determined before children start df = 3, p-value = school.17 0.0000001) 9.6%

Higher quality child care can help Premature Deliveries 11.4% 11.5% improve school readiness and enhance 10.7% 9.2% Signiﬁ cant language skills among children differences HEART DISEASE experiencing the negative developmental among groups (x2 = 21.7, effects of poverty.18 One study found df = 3, 7.6% 6.1% 5.1% p-value = 4.1% that young adults who had consistent 0.00007) child care as children scored higher on tests of academic skills, were more likely Infant Mortalities Signiﬁ cant (rate per 1000) differences STROKE to attend a four year college, and were 5.5 among groups more likely to still be in school at age (x2 = 11.7, 5.1% 4.8% 4.2% 3.9 3.3 3.8% 21.19 df = 3, 1.8 p-value = 0.008)

32 LOUISVILLE METRO HEALTH EQUITY REPORT

NINTH GRADE EDUCATION OR LESS (Percentage of People 25 or Older with 9th Grade Education or Less) 2005-2009 ACS ESTIMATE {

8.4% Portland Phoenix Hill-Smoketown 8.4% -Shelby Park Educational attainment is one 8.2% South Central Louisville of the strongest predictors of income, and income is directly 7.2% Shively related to our health.+ 6.7% Germantown

6.4% South Louisville Education indirectly impacts Downtown-Old Louisville health through enhanced access 6.4% -University to necessary resources (e.g., 6.3% Buechel-Newburg -Indian Trail health care). Further, as incomes 6.1% California-Parkland rise, people are more willing and able to pay for health care and 6.0% Russell Louisville Metro* preventive health care.++ Algonquin-Park Hill 5.8% -Park Duvalle rate is 4.1% 5.5% Fairdale *not including Airport Census Tracts

5.4% Valley Station

4.6% Chickasaw-Shawnee Downtown- Old Louisville- Phoenix Hill- 4.5% Pleasure Ridge Park Smoketown- University Chickasaw- Shelby Park Shawnee Northeast 4.4% Highview-Okolona Jefferson Portland Butchertown-Clifton Butchertown-Clifton- St. 4.2% -Crescent Hill Russell Crescent Hill Matthews California- 3.9% Southeast Louisville Parkland Highlands Algonquin - Park Hill - Park Duvalle German- town 2.9% J-town Southeast J-town South Louisville Central Shively Louisville Highlands 2.1% Buechel- Newburg-- Airport Fern Indian Trail 2.0% Fern Creek South Creek Louisville

1.5% Floyd's Fork Pleasure Ridge Park Floyd’s Fork Highview- 1.4% Northeast Jefferson Okolona

1.2% St. Matthews Fairdale Valley Station 5

Miles

+ Freudenberg, N., Ruglis, J. (2007). Reframing school dropout as a public health issue. Prev Chronic Dis, 4(4). Retrieved from: http://www.cdc.gov/pcd/issues/2007/oct/07_0063.htm. Accessed February 19, 2011. +Ross, C. & Mirowsky, J. (1999). Reﬁ ning the association between education and health: the effects of quantity, credential, and selectivity. Demography, 36(4), 445-460.

++Cutler, D. M. (2006). Education and health: Evaluating theories and evidence. National Bureau of Economic Research Working Paper 12352.

Education 33

BACHELOR’S DEGREE OR HIGHER (Percentage of People 25 or Older with at least a Bachelor’s Degree) 2005-2009 ACS ESTIMATE {

60.1% Highlands

54.9% Northeast Jefferson An individual’s health

53.2% St. Matthews is highly correlated

Butchertown-Clifton with success in school, 43.6% -Crescent Hill and the number of 39.1% Floyd's Fork years spent in school 37.3% J-town are major factors in 33.6% Southeast Louisville Louisville Metro* rate is 28.2% determining social and Downtown-Old Louisville 26.5% -University *not including Airport Census Tracts occupational status in 24.3% Fern Creek adulthood.+

21.4% Germantown Phoenix Hill-Smoketown 18.3% -Shelby Park

15.6% Highview-Okolona

14.1% South Louisville Buechel-Newburg 10.9% -Indian Trail Downtown- Old Louisville- Phoenix Hill- Smoketown- University 10.3% Pleasure Ridge Park Chickasaw- Shelby Park Shawnee Northeast Jefferson 10.1% Chickasaw-Shawnee Portland Butchertown-Clifton- St. Russell Crescent Hill Matthews 8.9% Shively California- Parkland Highlands Valley Station Algonquin - Park Hill - 8.3% Park Duvalle German- town Southeast J-town South Louisville 8.1% Fairdale Central Shively Louisville 7.7% South Central Louisville Buechel- Newburg-- Airport Fern Indian Trail South Creek 6.9% California-Parkland Louisville

Algonquin-Park Hill Pleasure Ridge Park 6.8% Floyd’s Fork -Park Duvalle Highview- Okolona 2.8% Russell Fairdale 2.7% Portland Valley Station 5

Miles

+ Ross, C. & Mirowsky, J. (1999). Reﬁ ning the association between education and health: the effects of quantity, credential, and selectivity. Demography, 36(4), 445-460.

34 LOUISVILLE METRO HEALTH EQUITY REPORT TRANSPORTATION

Transportation & Health they found that lower-income working While the lack of access to services and “Expanding the availability of, safety for, families ($20K-$35K) living away from employment is a problem for low-income and access to a variety of transportation employment centers spent 37% of their individuals, diffi culties with access options and integrating health-enhancing income on transportation.5 Another can affect anyone at any income level choices into transportation policy has study found that the poorest fi fth of auto- who lives in a part of town that lacks the potential to save lives by preventing owning Americans spend 42% of their alternative transportation options.13 Many chronic diseases, reducing and preventing annual household budget on automobile people must live far away from their jobs motor-vehicle-related injury and deaths, ownership, more than twice the national to fi nd affordable housing. Others choose and improving environmental health, average.6 the suburbs or more rural areas of the while stimulating economic development, county for other reasons. Regardless of and ensuring access for all people.”1 When faced with high housing costs, the basis for choosing a home outside of many families are forced to make the city-center, long commutes diminish Research shows that land-use planning diffi cult choices, primarily in the area of the amount of time for social/civic and transportation decisions, directly transportation.7 Many working families engagement and contribute to poor air and indirectly affect our health.2 Poor (whose incomes are between $20,000 and quality. Both the loss of time for other decisions in these areas can: $50,000) that move far from work to fi nd activities and the increase in air pollutants affordable housing, can end up spending have consequences on our health.14 • Reduce opportunities for physical much of their savings on transportation.8 activity, contributing to rising obesity and other negative health consequences Public Transit & Health associated with minimal exercise; Having an effi cient alternative to • Increase the amount of air pollution, automobile travel can contribute to the contributing to respiratory and health and vitality of a community. While cardiovascular illness and accelerating the lack of such a system can be a source climate change; of health risks for everyone, the inability • Increase traffi c accidents, and the to access public transit disproportionately injuries and deaths that result from these affects vulnerable populations: the poor, accidents; and the elderly, people who have disabilities • Exacerbate poverty and inequity by and children.9 People who cannot afford placing especially heavy burdens on a car or who are unable to drive face a vulnerable populations.3 relative lack of mobility options when it comes to jobs, housing, education, social Transportation Costs services, and activities.10 Lower income families are disproportionately affected by the absence The relationship between public of affordable forms of transportation. transportation and access to employment Households generally pay around 20% options has been the focus of many studies. of their income for transportation, but These studies have found signifi cant lower income families can spend a much employment effects from increased bus higher percentage of their more limited access and improved accessibility to resources. One study documented that employment hubs.11 In a study focusing on lower income families spend up to 30% single women receiving public assistance, IInn LouisvilleLouisville MetroMetro or more, depending on the location of the researchers found that women without 33.3%.3% ofof workersworkers neighborhood where they live.4 When an automobile experienced employment ccommuteommute viavia publicpublic these researchers looked at the data for 28 benefi ts from increased access to public ttransportationransportation ACS ESTIMATE 2005-2009 Metropolitan Statistical Areas (MSAs), transportation.12

Transportation 35 Further, every additional hour spent in a car in a rural area is double or even triple the per day is associated with a 6% increase rate in urban areas, as motor vehicles tend in the likelihood of obesity; while each to travel faster in rural areas.23 additional hour walked per day is associated Expanding the availability with a 4.8% reduction in the likelihood of While biking and walking can be healthy of, safety for, and obesity.15 Another study found that transit options for getting to employment or access to a variety of users met the recommended levels of services, pedestrians and bicyclists can face transportation options physical activity by walking to and from serious dangers in areas that are designed and integrating health- the transit stops.16 mainly for cars. Many communities enhancing choices into are taking on the safety challenge by transportation policy has improving their infrastructures and making the potential to save lives Pedestrian & Bicycle their roadways more accommodating to by preventing chronic Safety walkers and cyclists. One such approach diseases, reducing In the U.S., traffi c crashes continue to is Complete Streets. A “Complete Street” and preventing motor- be the greatest single cause of death and is safe, accessible, and convenient for all vehicle-related injury and disabilities for Americans 1-44 years of users, regardless of transportation mode, deaths, and improving age.17 Pedestrians and bicyclists are at an age, or physical disability.24 Complete environmental health, even greater risk of death from crashes than Streets adequately provide for bicyclists, while stimulating economic those who travel by motor vehicles.18 pedestrians, transit riders, and motorists; development, and ensuring and, they promote healthy communities access for all people. Areas with high traffi c volume can be and reductions in traffi c congestion by particularly dangerous, and higher rates of offering viable alternatives to driving. Centers for Disease Control, 2010 traffi c fl ow generally lead to higher rates of They are designed to prevent injury and to pedestrian injury.19 promote health.

Conversely, research has shown that areas with greater pedestrian ﬂ ows experience Average Annual Pedestrian Deaths per 100,000 (2000-2009) less risk of pedestrian-vehicle collision.20 Numerous studies show that motorists are less likely to collide with pedestrians and 1.7 cyclists if more people are walking and cycling.21 Such research helps demonstrate 1.3 that there is safety in numbers as more 1.1 1.0 people have the opportunity to walk or bike 0.9 to destinations. 0.8

The more rural, less developed areas of the county face different issues. They often lack pedestrian walkways such as Louisville KY Indianapolis IN Cincinnati OH MSA MSA MSA sidewalks, paths, and/or shoulders that Out of the 52 MSAs with at least one million inhabitants, the Louisville MSA are critical for pedestrian safety.22 Another ranks the 19th most dangerous for pedestrians. The Louisville MSA had 192 difference is the speed with which vehicles pedestrian fatalities from 2000 to 2009. travel. While there are more pedestrian/auto Transportation for America, 2011 collisions in urban areas, the risk of fatality

36 LOUISVILLE METRO HEALTH EQUITY REPORT

BICYCLE AND PEDESTRIAN COLLISIONS WITH MOTOR VEHICLES (Rate per 1000 people) 2009 KSP Collision Data {

Phoenix Hill-Smoketown 4.7 -Shelby Park 4.4 Downtown-Old Louisville -University In the U.S. trafﬁ c crashes 2.3 Russell continue to be the greatest

2.3 California-Parkland single cause of death and disabilities for Americans 1-44 2.1 Portland years of age.+ 1.7 Highlands Algonquin-Park Hill Pedestrians and bicyclists are 1.4 -Park Duvalle at an even greater risk of death 1.2 South Central Louisville from crashes than those who 0.9 St. Matthews travel by motor vehicles.++

0.8 Germantown Louisville Metro* rate is 0.76 Shively 0.7 *not including Airport Census Tracts Butchertown-Clifton 0.7 -Crescent Hill 0.7 South Louisville 0.7 Chickasaw-Shawnee Downtown- Old Louisville- Phoenix Hill- Smoketown- University Buechel-Newburg Chickasaw- Shelby Park 0.6 Shawnee Northeast -Indian Trail Jefferson Southeast Louisville Portland 0.6 Butchertown-Clifton- St. Russell Crescent Hill Matthews 0.5 Valley Station California- Parkland Highlands Algonquin - Park Hill - German- 0.5 Pleasure Ridge Park Park Duvalle town Southeast J-town South Louisville Central 0.4 Highview-Okolona Shively Louisville Buechel- 0.4 J-town Airport Newburg-- Indian Trail Fern South Creek 0.3 Floyd's Fork Louisville Pleasure Ridge Park Floyd’s Fork 0.3 Fern Creek Highview- Okolona 0.2 Northeast Jefferson Fairdale Valley 0.1 Fairdale Station 5

Miles

+Litman, T. (2003). Integrating public health objectives in transportation decision-making. Victoria Transportation Policy Institute. ++Centers for Disease Control and Prevention. (2010). CDC recommendations for improving health through transportation policy. Retrieved February 12, 2011, from http://www.cdc.gov/transportation/docs/ FINAL%20CDC%20Transportation%20Recommendations-4-28-2010.pdf.

Transportation 37 FOOD ACCESS Nutrition & Health education, and to die prematurely. Local Diet-related disease is one of the top • Lack of access to supermarkets is researchers have concluded that Louisville causes of preventable deaths among correlated with the prevalence of would show similar results given a more people in the U.S.1 Poor nutrition has been diet related diseases like diabetes complete analysis.9 known to cause or contribute to: obesity, and obesity.4 hypertension, high cholesterol, diabetes, heart disease, stroke, some cancers, and • The longer the distance necessary WEST LOUISVILLE FOOD other health problems. Research has to travel to a full service grocery ASSESSMENT found diet and nutrition to be especially store, the higher the body mass important for children because of the link index (BMI). For a 5’5” person, Research conducted by between hunger, malnutrition and delayed traveling 1.75 miles or more to brain development.2 get to a grocery store equaled a the West Louisville Food weight difference of about 5 pounds Assessment Research Food Access and Health compared to someone who did not Advisory Team found that cost have to travel that far.5 Evidence of the impact of these and quality of food available to challenges has been documented by many Louisville residents depends researchers. A few examples of research • Better access to a supermarket or in this area are listed below: large grocery store is associated on where they live within with healthier food intakes.6 the city. The problem was • Vehicle access is a major issue when particularly acute for residents living in a neighborhood with less • Limited knowledge about nutrition of the low-income West healthy food options, as residents among many individuals living Louisville and East Downtown in low-income communities are less in low-income neighborhoods, likely to own a car and less likely combined with a retail food areas who were likely to have to have a grocery store within their environment that offers few choices to spend more for healthy 3 neighborhood. for nutritious food and/or too foods and to have the least many options for less nutritious access to high-quality foods.10 alternatives, place these individuals at greater risk for poor health outcomes.7 The analysis found that West Louisville had only 1 full- Food Deserts service grocer per 25,000 The lack of grocery access has residents, compared to a caused many low-income, inner city neighborhoods to be labeled as Food Jefferson County ratio of Deserts. Food Deserts are “large and 1 grocery for every 12,500 isolated geographic areas with no, few, residents.11 or distant mainstream grocers offering a variety of fresh foods and nutritious foods that support a balanced and healthy The same report found that diet”.8 Research has demonstrated East Downtown was also that residents of food deserts are more underserved by supermarkets likely to suffer from diet related diseases and grocery stores.12 after controlling for race, income, and

38 LOUISVILLE METRO HEALTH EQUITY REPORT Convenience Stores and small food stores can be signiﬁ cantly between fast food restaurants and black Corner Stores higher than the cost in larger groceries and low income neighborhoods may The trend toward fewer and larger and supermarkets. contribute to an understanding of the grocery stores, often locating in environmental causes of the obesity the suburbs, caused more urban epidemic in these populations”.20 neighborhoods to meet their grocery Concentration of Fast needs through convenience and corner Food Retailers stores.14 These stores are easy to access Large concentrations of fast food for residents without transportation, restaurants are related to higher diet- they have convenient hours, and some related disease rates.18 People on limited provide culturally appropriate foods and incomes, such as young families, the The health implications products for immigrant communities.15 elderly and the unemployed, are least of living in a food desert However, they typically carry no or able to eat well, and often substitute were documented in a limited fresh produce, they sell a greater inexpensive, processed foods for fresh 2006 survey of residents food.19 While high-fat, high sodium fast proportion of processed foods, and in West Louisville, where they sometimes incorporate a fast-food food options are pervasive throughout 37% of respondents carry-out.16 many communities in the United States; their impact can be particularly harmful reported having high blood In one regional study, the USDA in neighborhoods where there are few pressure, 74% reported found that the average full-service other options. being overweight or obese supermarket offered three times as and 12% reported having many kinds of fruit, six times as many A study conducted in New Orleans found diabetes.13 kinds of vegetables, and nine times as that predominantly black neighborhoods many kinds of meat as the average small had 2.4 fast food restaurants per square store.17 In low-income neighborhoods, mile compared to 1.5 restaurants in access to healthy foods is further limited predominantly white neighborhoods by price, as the cost of food items in with the conclusion that, “the link

Food Access 39

FAST FOOD OUTLET DENSITY (Number of Fast Food Outlets per Square Mile) 2010 Food Inspection Data { Downtown-Old Louisville 16.0 -University 5.8 Germantown Large concentrations of fast food 5.6 St. Matthews (Including Mall St Matthews & Oxmoor Mall) restaurants are related to higher diet- related disease rates .+ 5.4 South Central Louisville

4.0 California-Parkland People on limited incomes, such as young families, elderly people and 4.0 Phoenix Hill-Smoketown -Shelby Park the unemployed, are least able to eat 3.7 Southeast Louisville well, and often substitute inexpensive, processed foods for fresh food.++ 2.9 Russell Buechel-Newburg Many poorer communities have 2.8 -Indian Trail more than their share of fast food 2.8 J-town restaurants that provide unhealthy, high-fat foods, and pose risks for 2.7 Butchertown-Clifton -Crescent Hill community nutrition.+++ 2.4 Highlands

2.2 Highview-Okolona Louisville Metro rate is 1.6 2.0 Fern Creek

Downtown- 2.0 South Louisville Old Louisville- Phoenix Hill- Smoketown- University Shelby Park Algonquin-Park Hill Chickasaw- 1.9 Shawnee Northeast -Park Duvalle Jefferson Portland 1.9 Portland Butchertown-Clifton- St. Russell Crescent Hill Matthews California- 1.8 Pleasure Ridge Park Parkland Highlands Algonquin - Park Hill - Park Duvalle German- town 1.8 Shively Southeast J-town South Louisville Shively Central 1.3 Valley Station Louisville Buechel- Airport Newburg- 1.0 Northeast Jefferson Indian Trail Fern South Creek Louisville 0.8 Chickasaw-Shawnee Pleasure Ridge Park Floyd’s Fork Highview- 0.2 Floyd's Fork Okolona

0.1 Fairdale Fairdale

Valley 5 Station Miles

+Centers for Disease Control and Prevention. (2010). CDC recommendations for improving health through transportation policy. Retrieved February 12, 2011, from http://www.cdc.gov/transportation/docs/FINAL%20CDC%20Transportation%20 Recommendations-4-28-2010.pdf.

++Wilkinson, R. & Marmot, M. (Eds.) (2003). Social determinants of health: The solid facts. Second edition. Denmark: World Health Organization

+++Community Farm Alliance/ West Louisville Food Working Group. (2007). Bridging the divide: Growing self-sufﬁ ciency in our food supply. Louisville, KY: Community Farm Alliance/West Louisville Food Working Group.

40 LOUISVILLE METRO HEALTH EQUITY REPORT HEALTH CARE ACCESS Access to quality, affordable health care 12.9 million people.3 The primary driver of this increase is the loss of employer- infl uences how a person uses health care PERCENT WITHOUT ANY TYPE OF and ultimately impacts the person’s health. sponsored coverage. HEALTH COVERAGE, AGES 25-65 People with good access to a trusted Louisville Metro BRFSS 2009 provider or primary care clinic are more • The average employee’s costs for health likely to use preventative services and have insurance rose, while income fell. 21.7% lower hospitalization rates.1 Conversely, Nationwide, the average cost an employee paid for a family insurance policy rose 81% people who experience barriers to health 14.8% from 2000 to 2008. During the same period, care, including the poor and the uninsured, median household income fell 2.5 percent suffer higher rates of disease and premature (adjusted for infl ation). Those with low death.2 incomes, including the working poor, make up a disproportionately large share of the WHITE BLACK OR AFRICAN While there are many factors that affect 4 n = 458 AMERICAN uninsured. n = 566 a person’s access to health care, primary **Blacks are more likely to be without any type of among them are: • In a 2010 analysis conducted by the Kaiser health coverage than whites x2 = 7.9, p-value = 0.002 Foundation, they found that 40% of the • Insurance coverage uninsured have family incomes below the • Location and operating hours of physician federal poverty level ($22,050 a year for eligibility rules are numerous and practices and available capacity among a family of four); and nine in ten of the complex, and vary by state, a person primary care uninsured have family incomes below 400% typically has to be poor, disabled or a providers 5 of poverty. member of a family with a dependent • Transportation child or a pregnant woman. • Language and cultural barriers When employer-based insurance is not available, some people are able to pay for Medicare is a resource for individuals The Role of Insurance their own private insurance. However, over the age of 65 and for people with A person’s health insurance status may be this is often very expensive, and is disabilities, who have contributed to the single most important determinant in beyond the reach of many individuals Medicare or are eligible through the whether or not an individual has access to who have limited fi nancial resources. Medicare contributions of a family primary care services. In the United States, member. Because Medicare does not there has been a long history of health More than one in fi ve adults under age adequately cover many outpatient insurance being part of the benefi t package 65 (22%) was uninsured in 2009, a services, most recipients purchase associated with full time employment. condition that puts both their health supplemental insurance to cover the This arrangement has worked fairly well 6 and their fi nancial security at risk. gaps. for those who are in salaried positions and African Americans, rural residents, and employed full time, or who are the spouse people with incomes between $10,000 Because health care costs have been or child of someone who is in one of these and $20,000 were most likely to have rising faster than benefi ciaries’ income, positions. inadequate coverage.7 the purchase of supplemental Medicare packages has become increasingly The employer-linked health care system is When the private sector does not address diffi cult for many people. In an becoming increasingly expensive, to the the need, many people turn to the public analysis conducted by the Kaiser Family employer and the employee; and, it leaves sector for coverage, through Medicaid or Foundation, ten percent (10%) of out those who are employed part-time, Medicare. However, these programs do Medicare recipients had no supplemental those who work as contractors, and those not cover everyone; and typically leave coverage in 2008. Among those who who are unemployed. out non-disabled adults between the ages were lacking supplemental coverage, of 22 and 65 who are not responsible for there was an over-representation of • A 2010 report by the Robert Wood Johnson individuals within the following groups: Foundation (RWJF) found that more a dependent child. people under-65 years of age, the middle-class Americans are uninsured. Medicaid is a state run program that disabled, the near poor (incomes between The total number of uninsured, middle- requires both income eligibility and $10,000 and $20,000), rural residents, class Americans increased by more than categorical eligibility. While the 8 2 million between 2000 and 2008, to and African Americans.

Health Care Access 41 and a means of obtaining recommended urban area with public transportation, preventive services.12 Living in a getting to medical appointments can be PERCENT WITH ANY TYPE OF HEALTH COVERAGE, poor neighborhood also reduces the a problem. The challenges include long Louisville Metro BRFSS 2002-2009 likelihood that a person will have travel times determined by the route map 85.6% 87.1% 85.5% 86.5% 87.6% 88.8% 87.9% 88.1% access to products and services, such as and the need for transfers; the diffi culties pharmacies or places to exercise, that associated with walking to the bus stop and are a part of recommended treatment boarding the bus while traveling with one or preventive care.13 These conditions or more young children. increase the likelihood of having unmet medical needs.14 A paper on the barriers to care presented a number of studies demonstrating how 2002 2003 2004 2005 2006 2007 2008 2009 In an effort to mitigate the disparities transportation can be a barrier to health 15 In 2009, 88% percent of Louisville Metro residents associated with the distribution of care. A few fi ndings from these studies reported some type of health care coverage. This is private sector practitioners, publicly are listed below: slightly higher than the nation (86%) and higher than funded clinics have been established the state (84%).9 in underserved areas. For example, • A analysis of data from the 2002 Behavioral Louisville Metro has a network of Risk Factor Surveillance System yielded the However, according to an analysis by the Louisville public health clinics and family health fi nding that 9% of people ages 65 and older Metro Department of Public and Health and Wellness care centers. Some of these clinics did not get needed medical care because of (LMPHW), the percent of Louisville Metro African operate under the direction of the transportation problems, suggesting that Americans who report having health care coverage Louisville Metro Department of Public they might be people living in rural areas, has decreased since 2004, with 75% reporting some Health and Wellness, while others are no longer drive, or depend on others or type of health coverage in 2008, compared to 79% in public transportation.16 2004.10 privately operated Federally Qualifi ed Healthcare Centers. • A door-to-door survey of the non-elderly In reviewing 2009 data from the Behavioral Risk urban poor found that 30% of respondents Factor Surveillance System (BRFSS), it can be seen Transportation & Health that while the proportion of white respondents ages Care Access had a transportation barrier to health 17 25-65 with some sort of insurance is comparable to Not having a working vehicle or the lack care. the state and national average rates, the percentage of access to public transportation can be for African American respondents ages 25-65 is much a signifi cant barrier to care. Even in an lower that the state and national average rates.

Federally Qualified Health Centers Neighborhoods and LMPHW Preventative Health Clinics Access to Health Care The location of physician practices and Family Health Center - Portland primary care providers also affect health care access. Even in an urban area with Park DuValle Family Health Center - East Broadway at City View LMPHW Middletown large numbers of practitioners, access to Phoenix Health Center Health Center for the Homeless care can be compromised by the geographic Park DuValle Community Health Center distribution of the primary care providers. Park DuValle at Newburg Family Health While there are signiﬁ cant variations Center - Iroquois Family Health LMPHW Newburg Health Center Center Americana between different neighborhoods and an individual’s ability to access primary LMPHW Dixie Health Center care, a neighborhood’s social capital and Family Health Center - Fairdale health care resources can signiﬁ cantly predict an individual’s access to primary 5 care.11 Living in neighborhoods with low Miles levels of investment has been found to reduce the likelihood that families and individuals will have a usual source of care

42 LOUISVILLE METRO HEALTH EQUITY REPORT • Research fi nds that public transportation from the following countries: Cuba, Haiti, the pain source is less important. Because barriers have adverse effects on the Columbia, Bhutan, Iraq, Iran, Afghanistan, they often use terms that are more general populations that depend most on them for Burma, Nepal, Somalia, Ethiopia, Congo, or vague, a Western trained physician may health services access, namely the poor and Sudan, and Rwanda. Recent arrivals and have diffi culty in understanding the reason 21 older persons.18 their languages are added to the already for the visit. diverse population of immigrants, including • Immigrants from Asia may believe that • One study described bus service to Vietnamese, Cambodian, and Bosnians. Western medications are too strong and may clinics as inconsistent, leading to missed While Catholic Charities, one of Louisville not take them in the prescribed doses. They appointments.19 This same study found Metro’s two resettlement agencies, has also may be at risk for drug interactions some bus stops to be poorly maintained and interpreters for 40 different languages, due to the concurrent use of herbs and other perceived to be unsafe by people trying to these individuals are not always available in traditional medicines.22 get to health care.20 the health care setting. Without an effective means of communication, it is diffi cult • Conservative values related to sexuality Louisville Metro has an extensive system for health care professionals to diagnose may contribute to female immigrants from of bus routes and a system for providing and prescribe the most effective forms of conservative cultures being less willing medical transportation through the public treatment. to obtain mammograms or gynecological transit system. Depending upon where a exams. person lives and where the person needs to go, their route can be complex and time A recent survey • Health prevention among Somalis is consuming. For example, the major routes of nearly 200 area practiced primarily through prayer and outside the Watterson Expressway tend Hispanics conducted living a life according to Islam. Many Somalis “believe that illness may be caused to follow a spoke-like design toward the by Norton Cancer by a communicable disease, by God, by city-center. If a person who lives beyond Institute and members spirit possession, or by the “evil eye”.23 the expressway and wants to travel a short of St. Rita Catholic distance to the west or east, it is likely that Church found that • Health literacy includes the ability to he/she will have to travel one route into the many — largely negotiate complex health care systems, city’s center, transfer buses, and ride the because of linguistic, understand doctor’s directions and consent second bus out beyond the expressway to cultural, and other forms and the instructions on prescription the desired location. 24 barriers — simply don’t drug bottles. Gaining effective access to know where to go for health care often assumes high levels of Language and cultural health literacy, regardless of education certain services. barriers to Health Care level and insurance status. Ensuring health Access Courier Journal - Jan. 21, 2011 equity means going beyond saddling health Two additional barriers relate to the growth www.courier-journal.com/article/20110121/ consumers with full responsibility for health NEWS01/301210083/New-survey-shows- and diversity of the immigrant population. Louisville-s-growing-Hispanic-population- literacy. While not only immigrant and refugee lacks-access-health-care populations face cultural barriers to health In summary, immigrants and refugees often care access, these communities face barriers face formidable challenges in their efforts to maintain health and receive care. Not only associated with language and culture in A person’s culture and traditions can also are they dealing with the shock and stress of addition to those mentioned previously. create barriers to accessing health care and acculturating to a new country, but they also The ability to communicate symptoms and to complying with the regimen of treatment. are subjected to new environmental risk medical history is severely compromised Much has been written on the role of factors. When these stressors are combined when the patient and provider do not culture in health and health care and the with the diffi culty in obtaining health care speak the same language or when a trained myriad of barriers that stem from different coverage and the language barriers they interpreter is not available. The number belief systems and values. However, the encounter in seeking care, it is not surprising and increasing diversity of immigrants and discussion is limited to a few examples that that they are at risk for diminished health refugees coming into the U.S., particularly relate to the cultures of recent refugees into outcomes. Health care providers and into the urban centers, have made these the Louisville Metro area: barriers even more formidable. For example, institutions need to proactively respond to in 2010, the two resettlement agencies • Haitians tend to believe that pain affects the a broader range of cultural, language and within Louisville Metro resettled people whole body system; therefore the origin of health literacy capabilities.

Health Care Access 43

LANGUAGE OTHER THAN ENGLISH SPOKEN AT HOME Population 5 years and over { 2005-2009 ACS ESTIMATE

15.7% South Louisville • The ability to communicate symptoms and medical history is Buechel-Newburg 9.3% -Indian Trail severely compromised when the patient and provider do not speak 9.0% Downtown-Old Louisville -University the same language or when a 8.5% J-town trained interpreter is not available.

Phoenix Hill-Smoketown • The number and increasing 8.4% -Shelby Park diversity of immigrants and 8.4% Southeast Louisville refugees coming into the U.S., particularly into the urban Northeast Jefferson 7.9% centers, have made these barriers even more formidable. 7.8% Fairdale

7.6% South Central Louisville

7.2% Highview-Okolona

7.2% Butchertown-Clifton Louisville Metro* -Crescent Hill rate is 6.8% 6.0% Floyd's Fork *not including Airport Census Tracts

5.1% Fern Creek

5.1% Germantown

4.6% St. Matthews

4.5% Highlands Northeast Jefferson Portland Butchertown-Clifton-Crescent Hill 2.9% Chickasaw-Shawnee St. Matthews Russell Russell Phoenix Hill-Smoketown-Shelby Park Downtown-Old Louisville-University California-Parkland Highlands 2.9% Shively Algonquin-Park Hill-Park Duvalle Germantown J-town Algonquin-Park Hill Southeast Louisville 2.6% -Park Duvalle Shively South Central Louisville 2.5% Pleasure Ridge Park Buechel-Newburg-Indian Trail

South Louisville Airport Fern Creek 2.2% California-Parkland Floyd's Fork Pleasure Ridge Park

1.9% Valley Station Highview-Okolona

1.4% Portland Fairdale

1.3% Chickasaw-Shawnee Valley Station 5 Miles

44 LOUISVILLE METRO HEALTH EQUITY REPORT NO VEHICLES AVAILABLE (as a Determinant of Health Care Access) { Occupied Housing Units with No Vehicles 2005-2009 ACS ESTIMATE Phoenix Hill-Smoketown • A door-to-door survey 49.4% -Shelby Park of the non-elderly urban 43.3% Russell poor showed that 30% of respondents had a Downtown-Old Louisville 37.2% transportation barrier to -University health care.+ 34.4% California-Parkland • Research ﬁ nds that 30.7% Portland public transportation Algonquin-Park Hill barriers have adverse 29.5% -Park Duvalle effects on the populations that depend most on 18.9% Chickasaw-Shawnee them for health services 18.9% South Central Louisville access, namely the poor and older persons.++ Buechel-Newburg 13.8% -Indian Trail 12.7% Shively

12.1% Germantown

11.4% South Louisville Louisville Metro* rate is 9.7% 8.6% Butchertown-Clifton -Crescent Hill *not including Airport Census Tracts 6.5% Southeast Louisville Downtown- Old Louisville- Phoenix Hill- Smoketown- 6.3% Highlands University Chickasaw- Shelby Park Shawnee Northeast 5.5% Pleasure Ridge Park Jefferson Portland Butchertown-Clifton- St. 5.2% Valley Station Russell Crescent Hill Matthews California- Parkland Highlands 5.0% St. Matthews Algonquin - Park Hill - Park Duvalle German- town Southeast J-town 4.6% Highview-Okolona South Louisville Central Shively Louisville 4.5% Fairdale Buechel- Airport Newburg-- Indian Trail Fern 4.2% J-town South Creek Louisville

3.4% Fern Creek Pleasure Ridge Park Floyd’s Fork Highview- 3.0% Northeast Jefferson Okolona

1.8% Floyd's Fork Fairdale Valley Station 5

Miles

+ Ahmed, S., Lemkau, J., Nealeigh, N., & Mann, B. (2001). Barriers to healthcare access in non- elderly urban poor American poplantion. Health and Social Care in the Community, 9(6), 445-453.

++ Rittner, B. & Kirk, A. (1995). Health care and public transportation use by poor and frail elderly people. Social Work, 40(3), 365-373.

Health Care Access 45 COMMUNITY SAFETY Crime, Insecurity, and diseases.4 And, once released, they may Health bring these conditions back to their Crime is a public health issue, and has families and their neighborhoods. implications for the victims and their social networks, as well as the perpetrators The Role of the Built and their families. Crime can directly Environment affect health, through physical harm and The physical condition of the properties emotional trauma; and the fear of violent in a neighborhood along with the types crime can indirectly affect health, through of businesses within a neighborhood can increased rates of anxiety and stress.1 play a role in community safety. A study Threatened by crime or other forms of conducted by the Baltimore City Health insecurity, our bodies react in the form Department (2010) found that negative of fear, anxiety, depression, dizziness, health and safety outcomes are associated chest pains, trouble breathing, nausea, with pockets of vacant properties, upset stomach, and weakness, which including assault-related injuries, CCrimerime isis a all come together to contribute to poor homicide, and fi re-related injuries.5 In a ppublicublic healthhealth health.2 The fear of crime can also lead to study on the impact of home foreclosures iissue,ssue, andand hashas social isolation, and loss of opportunities on public health (Alameda County, iimplicationsmplications for exercise within a crime threatened California), researchers summarized the fforor thethe victimsvictims environment. problem with the following statement: aandnd theirtheir socialsocial “In addition to being an eyesore and nnetworks,etworks, asas wwellell asas thethe Research also has documented that visual reminder of neighborhood pperpetratorserpetrators aandnd criminal victimization can affect the instability, vacant properties can attract ttheirheir families.families. victim’s self perception of their own rodents and mosquitos, vandalism, health.3 Even after the physical wounds trespassing, drug dealing, and other have healed, and even when there is no illegal activities.”6 Researchers also have in low-income communities has implications physical evidence of injury remaining, found that the presence of abandoned for health and quality of life in these victims can believe themselves to be buildings, overgrown lots, and graffi ti, neighborhoods.9 “damaged goods”. This perception can often associated with vacant properties, affect self esteem and be a trigger for can lead to an increase in perceived •Higher concentrations of liquor stores are depression. crime, and the fears associated with that associated with higher levels of crime.10 A perception.7 Ultimately, the presence of study by Gruenewald and Remer (2006) found The impact of crime and the criminal vacant homes can contribute to a loss of that “each six (6) additional liquor outlets justice system can also have health neighborhood cohesion and a decrease accounted for one additional violent assault implications for the perpetrator and for in property values, particularly in that resulted in at least one overnight stay at the neighborhoods into which they return. neighborhoods that may already have low a hospital”.11 Individuals involved in the criminal levels of investment.8 This loss in home justice system often have poor health values diminishes wealth and contributes •Higher rates of liquor outlets in a and numerous health risks before the to the poverty that is associated with poor neighborhood are associated with higher commission of the crime. These risks can health and poor access to health care. rates of motor vehicle accidents.12 include poverty, lower levels of education, limited job prospects, inadequate housing, A high density of liquor outlets in a •Higher concentrations of liquor outlets are and higher incidences of substance abuse. neighborhood presents particular risks. associated with increased perceptions of Once incarcerated, they are exposed to a Research in this area has found: insecurity and limited walkability, contributing population with signifi cantly higher rates to lower levels of physical activity.13 of HIV, tuberculosis, and other infectious • The higher density of liquor outlets found

46 LOUISVILLE METRO HEALTH EQUITY REPORT This exposure to violence and the concern about safety also impact a child’s

0.1 - 0.5 Downtown- ability to engage in outdoor, Old Louisville- Phoenix Hill- Smoketown- University 0.6 - 1.0 Chickasaw- Shelby Park physical activities in their Shawnee Northeast 1.1 - 2.0 Jefferson neighborhood.19 Unless Portland Butchertown-Clifton- St. 2.1 - 6.4 Russell Crescent Hill Matthews exercise and the Vitamin California- Parkland Highlands D that comes through Algonquin - Park Hill - Park Duvalle German- town sunshine is obtained in other Southeast J-town South Louisville Central ways, restricted outdoor Shively Louisville Buechel- play time can contribute to Newburg-- Airport Fern Indian Trail South Creek obesity and to the problems Louisville associated with vitamin Pleasure Ridge Park Floyd’s Fork Highview- D deﬁ ciencies, including Okolona loss of bone strength and Fairdale Valley diminished immunity to a Station 5 Miles host of chronic diseases.

While children may suffer from child abuse and are the indirect victims of other crimes, the concern As with most other social determinants of Safety of Young People about youth-on-youth violence extends to health, the impact of crime and insecurity Safety concerns for children and youth both perpetrators and victims. In 2008, can have a devastating effect on the can cover a wide range of threats, and the national Conference of Mayors and biological, psychological and social include child abuse, dating violence, the Prevention Institute called for youth development of children and adolescents. youth-on-youth violence, and other violence to be treated as a public health forms of harm by adults. According crisis. The reasons for their concern Even when researchers control for to the Centers for Disease Control and were present in data on emergency socioeconomic status, children living Prevention (CDC), one in every four teens room utilization and criminal justice in urban communities who are exposed self-report physical, verbal, emotional involvement. In 2007, over 696,000 to violence are more likely than other or sexual abuse every year.14 A second young people in the U.S. ages 10 to 24 children to become victims or perpetrators report from research conducted under years were treated in emergency rooms for of the same kind of violence later in life.17 the auspices of the CDC found that one injuries sustained as a result of violence.20 One study found that being a victim of in eleven (1 in 11) adolescents reported In some cases, these injuries lead to death. violence during adolescence carried a 38% having been the victim of physical dating The U. S. Bureau of Justice Statistics cites higher likelihood that the young person violence.15 The effects on victims are that homicide is among the leading causes affected would have worse employment serious, not only including the immediate of death among youth between the ages of experiences, be more likely to commit a physical injuries, but the longer term 10 and 24; and, for every homicide, there crime, and be less likely to have a positive health problems like post traumatic stress are close to 1,000 nonfatal violent assaults support network.18 disorder (PTSD), depression, anxiety, and involving young people.21 substance abuse.16

Community Safety 47

SERIOUS CRIMES, RATE PER 10,000* Number of Assaults, Burglaries,677 and Homicides/ACS 2005-2009 Population { 2010 Louisville Metro 555Police Data 466 235 California-Parkland Crime can directly affect health, through physical 221 Phoenix Hill-Smoketown -Shelby Park harm and emotional trauma; 205 Russell and the fear of violent crime can indirectly affect health, 197 Portland through increased rates of + Downtown-Old Louisville anxiety and stress. 163 -University 131 South Central Louisville Threatened by crime or other forms of insecurity, our bodies Algonquin-Park Hill 125 -Park Duvalle react in the form of fear, anxiety, depression, dizziness, Shively* 118 chest pains, trouble breathing, 106 Chickasaw-Shawnee nausea, upset stomach, and weakness, which all come Buechel-Newburg together to contribute to poor 102 -Indian Trail health.++ 63 South Louisville Louisville Metro* 63 Germantown rate is 54 40 Pleasure Ridge Park *not including Airport and St. Matthews Census Tracts

32 Highlands Downtown- Old Louisville- Phoenix Hill- Smoketown- University Chickasaw- Shelby Park 31 Southeast Louisville Shawnee Northeast Jefferson Valley Station Portland 31 Butchertown-Clifton- St. Crescent Hill Butchertown-Clifton Russell Matthews California- 31 -Crescent Hill Parkland Highlands Algonquin - Park Hill - Park Duvalle German- 27 Fairdale town Southeast J-town South Louisville Central 26 Highview-Okolona Shively Louisville Buechel- Fern Creek Airport Newburg-- 12 Indian Trail Fern South Creek 11 J-town Louisville Pleasure Ridge Park Floyd’s Fork 10 Northeast Jefferson Highview- Okolona

9 Floyd's Fork Fairdale Valley Station

Miles

++ Middleton, J., 1998. Crime is a public health problem. Medicine, conﬂ ict, and survival. Jan- Mar;14(1):24-8.

+Hill TD, Ross CE, Angel RJ. 2005. Neighborhood disorder, psychophysiological distress, and health. Journal of Health and Social Behavior 46 (2):170-186.

48 LOUISVILLE METRO HEALTH EQUITY REPORT

VACANCY RATES (as a Determinant of Neighborhood Safety) Residential Vacancies/Total Residences { 2010 USPS ESTIMATES

21.2% California-Parkland In addition to being an 20.3% Portland eyesore and visual reminder of neighborhood instability, vacant 13.7% Russell properties can attract rodents 12.7% Algonquin-Park Hill and mosquitos, vandalism, -Park Duvalle trespassing, drug dealing, and 12.3% Chickasaw-Shawnee other illegal activities.+ Phoenix Hill-Smoketown 12.1% -Shelby Park Researchers also have found South Central Louisville 9.8% that the presence of abandoned Downtown-Old Louisville buildings, overgrown lots, and 9.0% -University grafﬁ ti, often associated with 6.1% Germantown vacant properties, can lead to an

5.9% Shively increase in perceived crime, and the fears associated with that 4.6% South Louisville perception.++

4.4% Valley Station Louisville Metro* rate is 4.3%

4.0% Highlands *not including Airport Census Tracts Buechel-Newburg 3.5% -Indian Trail Downtown- 3.3% Fairdale Old Louisville- Phoenix Hill- Smoketown- University Chickasaw- Shelby Park 2.7% Southeast Louisville Shawnee Northeast Jefferson Portland 2.6% Highview-Okolona Butchertown-Clifton- St. Russell Crescent Hill Matthews California- 2.6% Pleasure Ridge Park Parkland Highlands Algonquin - Park Hill - Butchertown-Clifton Park Duvalle German- 2.5% town -Crescent Hill Southeast J-town South Louisville Central 1.9% J-town Shively Louisville Buechel- Newburg-- 1.6% Fern Creek Airport Fern Indian Trail South Creek Louisville 1.0% St. Matthews Pleasure Ridge Park Floyd’s Fork 0.9% Northeast Jefferson Highview- Okolona 0.9% Floyd's Fork Fairdale Valley Station 5

Miles

+Just Cause and Alameda County Public Health Department. (2010). Rebuilding neighborhoods, restoring health: A report on the impact of foreclosures on public health. Oakland, CA.

++Taylor RB. The Incivilities or ‘Broken Windows’ Thesis. Department of Criminal Justice. Temple University. Philadelphia, PA

Community Safety 49 PARKS & PHYSICAL ACTIVITY

Physical Activity and Health Adults with 20+ minutes of • Without outdoor places to play, vigorous physical activity three children are less likely to get regular or more days per week The physical characteristics of a exercise and may face elevated risks Louisville Metro BRFSS, 2009 neighborhood, the presence of sidewalks, for diabetes and obesity.9 parks, and houses with front porches, can encourage physical activity and neighbor YES • A study included in the American to neighbor relationships. Parks and public 22.1% Journal of Preventative Medicine spaces provide affordable opportunities found that access to a place to exercise for physical activity and they function as NO results in a 5.1 percent median places to socialize and build community. increase in aerobic capacity, along They are places for scheduled and 77.9% with a reduction in body fat, weight supervised activities for youth, and they loss, improvements in ﬂ exibility, and can be places of refuge to enjoy nature.1 an increase in perceived energy.10

• Spending time in a natural Historically, physical activity was a • Not getting enough exercise is environment and green space can greater part of the day-to-day routine. a contributing cause of coronary have a positive effect on health People worked in jobs that demanded heart disease, colon cancer, and and wellbeing. It can reduce stress physical exertion, they often lived near diabetes, and modest increases in and fatigue and improve mental their workplace and could walk to work, physical activity are associated with health.11 and they had less access to private substantial reductions in the negative transportation. Today, people have to health outcomes related to these While the health benefi ts of physical be more intentional about exercise; conditions.4 and for those who cannot afford gym activity are far ranging, many people fi nd it diffi cult to maintain a routine that includes memberships or team registration fees; • Physical activity levels are highly the recommended amount of activity. A public parks can be an excellent option. related to obesity, one of the fastest study published in 2003, in the journal of For these venues to be used, they must be rising public health problems. In 2 Physical Activity and Public Health, found perceived as attractive, clean, and safe. 2008, over 16% of children were that more than half of U.S. adults are not When park space becomes neglected, and obese (12 million are overweight); physically active on a regular basis; and is either overgrown or strewn with trash and the majority of adults (66%) are that 1 in 4 adults report no leisure-time and broken glass, and when it becomes a overweight or obese.5 haven for crime or for people perceived as activity at all.12 threatening to others, then it is less likely • Parks provide opportunities for to be used. physically active lifestyles by providing relatively inexpensive Access to Opportunities The research base related to the connection options for exercise and recreation.6 for Physical Activity between physical activity and health is Parks, recreational facilities, and other considerable. Selected fi ndings from • According to a study conducted by public spaces in low-income neighborhoods that research are provided below. These the CDC, enhanced access to spaces are often underutilized because of a fear of are just a few examples of the myriad for physical activity resulted in 25% crime or a lack of adequate maintenance.13 of implications of physical activity and more people exercising three or more Many communities with high densities exercise on health: days per week.7 of people of color have fewer physical activity facilities and a decreased number • Physical activity is associated with • Having a place to be physically of facilities has been associated with lower reductions in premature mortality, the active, combined with outreach rates of moderate to vigorous physical prevention of chronic diseases and and education, can produce a 48% 3 activity.14 improvements in mental health. increase in frequency of physical activity.8

50 LOUISVILLE METRO HEALTH EQUITY REPORT

ASSAULTS NEAR PARKS Assaults within 1000 ft of Metro677 Parks, (Rate per 10,000 people) 555 { 2010 Louisville Metro Police Data 466 73.9 Portland Crime can serve as a Phoenix Hill-Smoketown 72.2 -Shelby Park very serious to barrier to the accessibility of Russell 50.9 parks, even if parks 41.4 California-Parkland are nearby and contain quality exercise Algonquin-Park Hill amenities. While many 25.4 -Park Duvalle poorer neighborhoods 22.2 Downtown-Old Louisville -University may have a greater proximity-based access 17.4 South Central Louisville than people in suburban 15.9 Chickasaw-Shawnee Louisville Metro* or rural Louisville, overall rate is 15.2 access is likely limited by 7.5 Buechel-Newburg -Indian Trail *not including Airport and St. perceptions of safety in Matthews Census Tracts parks. 6.7 South Louisville

5.7 Germantown

4.3 Butchertown-Clifton -Crescent Hill

3.5 Highlands Downtown- Old Louisville- Phoenix Hill- Smoketown- Fairdale University 3.3 Chickasaw- Shelby Park Shawnee Northeast 2.9 Southeast Louisville Jefferson Portland Butchertown-Clifton- St. Crescent Hill 2.4 Shively Russell Matthews California- Parkland Highlands 2.3 Valley Station Algonquin - Park Hill - Park Duvalle German- town Southeast J-town 1.5 Highview-Okolona South Louisville Central Shively Louisville 0.7 Floyd's Fork Buechel- Airport Newburg-- Indian Trail Fern Northeast Jefferson South Creek 0.5 Louisville

Pleasure Ridge Park 0.5 Pleasure Ridge Park Floyd’s Fork Highview- Okolona 0.4 J-town Fairdale 0.0 Fern Creek Valley Station 5

Miles

Parks & Physical Activity 51 CONCLUSION

Like their fellow Americans, Louisvillians born at the beginning of the 21st century can expect to live, on average, 30 years longer than people born at the beginning Healthy of the 20th century. The introduction of antibiotics, vaccines and other medical People 2020 advances have been important, but the majority of the increase in life expectancy Charge can be attributed to improvements in our physical and social environments. Clean water, clean air, effective sewer systems, safe food production, workplace and ‘Create social traffi c safety, restrictions on the sale and use of tobacco products and improvements and physical in housing conditions have yielded the greatest benefi ts. Yet, these benefi ts have environments that not been uniformly distributed across neighborhoods, races, and socioeconomic lines. promote good health for all’ Healthy People 2020 charges us to ‘Create social and physical environments that promote good health for all’ as one of four overarching goals for the decade. It is clear from the information and analysis presented in this report that in order to ensure all Louisvillians have the opportunity for good health, advances are needed well beyond health care and the traditional health sectors. As shown, population health to a large extent is determined by living conditions and other social and economic factors, and are therefore often best infl uenced by policies and actions in fi elds such as education, childcare, housing, business, law, media, community planning, transportation and agriculture. Making these advances, therefore requires working together to explore how programs, practices and policies in these areas affect the health of individuals, families, and communities. Our embrace of a “health in all policies” approach would facilitate common goals, complimentary roles, and ongoing constructive relationships between public health, health care and other critical sectors.

The Center for Health Equity works to eliminate social and economic barriers to good health. As a catalyst for collaboration between communities, organizations and government entities, The Center commissioned this report as a starting point for community-wide conversations to reshape the public health landscape. As a starter ‘health equity lens’, the determinants of health underscore the need for an explicit concern for health and equity in all areas of policy. The focus of this approach extends beyond individual factors and lifestyles, to addressing how these can be inﬂ uenced by complimentary policy-related strategies contributing to improved population health.

Going forward, community participation and insight are critical as we actively seek to create the social and physical environments that will promote good health for all Louisvillians.

Join the conversation!

52 LOUISVILLE METRO HEALTH EQUITY REPORT REFERENCES

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5 Ibid. Ewing, R., Frank, L., & Kreutzer, R. (2006). Understanding 7 United States Department of Agriculture. (2009). the relationship between public health and the built Access to affordable and nutritious food: Measuring and 6 Surface Transportation Policy Project. Transportation environment: A report to the LEED-ND Core Committee. understanding food deserts and their consequences. and Health. Retrieved February 13, 2011, from: http:// Washington, DC: Government Printing Offi ce. www.transact.org/library/factsheets/health.asp. 20 Leden, L. (2002). Pedestrian risk decreases with pedestrian fl ow: A case study based on data from 8 Gallagher, M. (2007). Key sections of central Louisville 7 Lipman, B. (2005). Something’s Gotta Give: Working signalized intersections in Hamilton, Ontaria. Accident are “food imbalanced”. Chicago, IL: Mari Gallagher Families and the Cost of Housing. Center for Housing Analysis and Prevention, 34, 457-464. Research & Consulting. Policy. Geyer, J., Raford, N., Ragland, D., & Pham, T. (2005). The continuing debate about safety in numbers – data 9 Ibid. 8 Lipman, B. (2006). Heavy load: The combined housing from Oakland, CA. UC Berkeley Traffi c Safety Center: and transportation burdens of working Families. Center UCB-TSC-RR-TRB3. 10 Community Farm Alliance/ West Louisville Food for Housing Policy. Working Group. (2007). Bridging the divide: Growing self- 21 Jacobsen, P. L. (2003). Safety in numbers: More suffi ciency in our food supply. Louisville, KY: Community 9 Center for Quality Growth and Regional Development, walkers and bicyclists, safer walking and bicycling. Injury Farm Alliance/West Louisville Food Working Group. Georgia Institute of Technology. (2006). Healthy Housing: Prevention, 9, 205-209. Forging the Economic and Empirical Foundation. Atlanta, 11 Ibid. GA: Georgia Institute of Technology. 22 Pedsafe. Pedestrian safety guide and countermeasure selection system. Retrieved from: http://www.walkinginfo. 12 Ibid. 10 Litman, T. (2009). Transportation costs & benefi ts: org/pedsafe/crashstats.cfm. resources for measuring transportation costs and benefi ts. 13 Mayor’s Healthy Hometown Movement. (2010). The Victoria, BC: Victoria Transport Policy Institute. 23 World Health Organization. (2004). World Report on state of food: A snapshot of food access in Louisville. road traffi c injury prevention. Edited by Margie Penden, Louisville, KY: Mayor’s Healthy Hometown Movement, 11 Kawabata, M. (2002). Job accessibility by travel mode Richard Scurfi eld, David Sleet, et al. Food in Neighborhoods Committee. in US metropolitan areas. Papers and proceedings of the Geographic Information Systems Association, 11, 24 McCann, B. (2005). Complete the streets! Planning, 5, 14 Morland, K., Wing, S., Diez Roux, A., & Poole, C. 115-120. 18-23. (2002). Neighborhood characteristics associated with the location of food stores and food service places. American Ong P. & Houson, D. (2002). Transit, employment, and Thunderhead Alliance. (2006). Guide to complete streets Journal of Preventive Medicine, 22(1), 23-29. women on welfare. Urban Geography, 23, 344-364. campaigns. Washington, DC: Thunderhead Alliance. Eisenhauer, E. (2001). In poor health: Supermarket 12 Ong P. & Houson, D. (2002). Transit, employment, and redlining and urban nutrition. GeoJournal, 53(2), 125-133. women on welfare. Urban Geography, 23, 344-364. FOOD ACCESS 15 D.C. Hunger Solutions. (2006). Healthy food, healthy 13 Center for Quality Growth and Regional Development, communities: An assessment and scorecard of community 1 US Department of Health and Human Services. (2001). Georgia Institute of Technology. (2006). Healthy Housing: food security in the District of Columbia. D.C. Hunger The Surgeon General’s call to action to prevent and Forging the Economic and Empirical Foundation. Atlanta, Solutions/ Food Research and Action Center. decrease overweight and obesity. Washington, DC: GA: Georgia Institute of Technology. Government Printing Offi ce. Retrieved from: http://www. 16 Williams, D. & Collins, C. (2001). Racial residential surgeongeneral.gov/topics/obesity. Accessed March 18, 14 Fassinger, P. & Adams G. (2006). A place to call home: segregation: A fundamental cause of racial disparitites in 2011. housing in the San Francisco Bay Area. Oakland, CA: health. ASPH Public Health Reports, 116, 404-416. US Association of Bay Area Governments. Dept of Agriculture, Economic Research Service. 2002. 2 Christopher, G. (2005). Let them eat cake or fat… Trend U.S. Food Marketing System; Agriculture Marketing Letter Health Report (May/June 2005), Joint Center for 15 Frank, L., Andresen, M., & Schmid, T. (2004). Obesity Report No. 811. Political and Economic Studies. relationships with community design, physical activity, and time spent in cars. American Journal of Preventive 17 Christopher, G. (2005). Let them eat cake or fat… Trend 3 Morland, K., Wing, S., Diez, R. A. & Poole, C. (2002). Medicine, 27(2), 87-96. Letter Health Report (May/June 2005), Joint Center for Neighborhood characteristics associated with the location

56 LOUISVILLE METRO HEALTH EQUITY REPORT Political and Economic Studies. 7 Kaiser Family Foundation. (2010). Medicaire at a glance. Washington, DC: Kaiser Family Foundation. 23 Minnesota’s Children’s Hospital. (2003). Somali 18 Morland, K., Wing, S., Diez Roux, A., & Poole, C. culture and medical traditions. Retrieved from: http:// (2002). Neighborhood characteristics associated with 8 Ibid. www.mbali.info/doc326.htm. Accessed March 31, the location of food stores and food service places. 2011. American Journal of Preventive Medicine, 22(1), 23-29. 9 Centers for Disease Control and Prevention. (2009). Nationwide (States and DC) – 2009 Health Care 24 National Network of Libraries of Medicine http://nnlm. 19 Wilkinson, R. & Marmot, M. (Eds.) (2003). Social Access/Coverage. gov/outreach/consumer/hlthlit.html determinants of health: The solid facts. Second edition. (Originally produced by Penny Glassman, former Denmark: World Health Organization. 10 Louisville Metro Department of Public and Health and Wellness. (2009). Louisville Metro Health Status Technology Coordinator, National Network of 20 Community Farm Alliance/ West Louisville Food Report. Louisville, KY: Louisville Metro Department of Libraries of Medicine New England Region, Working Group. (2007). Bridging the divide: Growing Public and Health and Wellness. Shrewsbury, MA). self-suffi ciency in our food supply. Louisville, KY: Community Farm Alliance. 11 Prentice, J. C. (2006). Neighborhood effects on primary care access in Los Angeles. Social Science & Block, J., Scribner, R., & DeSalvo, K. (2004). Fast food, Medicine, 62, 1291-1303. race/ethnicity, and income: A geographical analysis. Am J Prev Med, 27(3), 211-217. 12 Kirby J. and Kaneda T. (2005). If neighborhood COMMUNITY SAFETY socioeconomic disadvantage and access to health 1 21 United States Department of Agriculture. care. Journal of Health and Social Behavior, 46(1), Middleton, J. (1998). Crime is a public health (2009). Access to affordable and nutritious food: 15-31. problem. Medicine, Confl ict, and Survival, 14(1), 24-8. Measuring and understanding food deserts and their 2 consequences. Washington, DC: Government Printing 13 Marmot, M., Shipley, M., & Rose, G. (1984). Hill, T.D., Ross C.E., & Angel R.J. (2005). Offi ce. Inequalities in death-specifi c explanations of a general Neighborhood disorder, psychophysiological distress, pattern? Lancet, 1(8384), 1003-1006. and health. Journal of Health and Social Behavior, 46 22 Morland K., Wing, S., Diez Roux, A., & Poole, C. (2), 170-186. (2002). Neighborhood characteristics associated with 14 Kirby, J. & Kaneda, T. (2005). If neighborhood 3 the location of food stores and food service places. socioeconomic disadvantage and access to health Britt, C. (2001). Health consequences of criminal American Journal of Preventive Medicine, 22(1), 23-29. care. Journal of Health and Social Behavior, 46(1), victimization. International Review of Victomology, 8(1), 15-31. 63-73. 23 Wilkinson, R. & Marmot, M. (Eds.) (2003). Social 4 determinants of health: The solid facts. Second edition. 15 Shook, M. (2005). Transportation barriers and health Williams, N. (2007). Prison health and the health of Denmark: World Health Organization. access for patients attending a community health the public: Ties that bind. Journal of Correctional Health center. (Field Area Paper). Retrieved from: http://web. Care, 13(2), 80-92. 24 Community Farm Alliance/ West Louisville Food pdx.edu/~jdill/Files/Shook_access_transportation_chc. 5 Working Group. (2007). Bridging the divide: Growing pdf. Accessed March 2, 2011. Baltimore City Health Department. (2010). 2010 self-suffi ciency in our food supply. Louisville, KY: Health Disparities Report Card. Baltimore City Health Community Farm Alliance. 16 Okoro, C., Strine, T., Young, S., & Balluz, S. (2005). Department. Access to health care among older adults and receipt 6 25 Ibid. of preventative services. Results from the Behavioral Just Cause and Alameda County Public Health Risk Factor Surveillance System, 2002. Preventative Department. (2010). Rebuilding neighborhoods, Medicine, 40, 337-343. restoring health: A report on the impact of foreclosures on public health. Oakland, CA. HEALTH CARE ACCESS 17 Ahmed, S., Lemkau, J., Nealeigh, N., & Mann, B. 7 (2001). Barriers to healthcare access in non-elderly Taylor R. (2005). The incivilities or ‘broken windows’ 1 Bindman, A., Grumback, K., & Osmond, D. (1995). urban poor American poplantion. Health and Social thesis. Department of Criminal Justice, Temple Preventable hospitalizations and access to care. Care in the Community, 9(6), 445-453. University. Philadelphia, PA. Journal of the American Medical Association, 274(4), 8 305-311. 18 Rittner, B. & Kirk, A. (1995). Health care and public Gonzalez-Rivera, C. (2009). People of color hardest transportation use by poor and frail elderly people. hit by the foreclosure crisis. The Greenlining Institute, 2 Clancy, C. & Stryker, D. (2001). Racial and ethnic Social Work, 40(3), 365-373. Berkeley, CA. disparities and the primary care experience. Health 9 Services Research, 36, 979-986. 19 Pheley, A. (1999). Mass transity strike effects on Gorman, D., & Speer, P. (1997). The concentration access to medical care. Journal of Health Care for the of liquor outlets in an economically disadvantaged city 3 Robert Wood Johnson Foundation. (2010). Report: Poor and Uninsured, 10(4), 389-396. in the northeastern United States. Substance Use and America’s middle class shouldering the brunt of health Misuse. 32, 2033-2046. insurance crisis. Princeton, NJ: Robert Wood Johnson 20 Ibid. Foundation. Stewart, K. How alcohol outlets affect neighborhood 21 Phelps, L. (2004). Cultural competency and Haitian violence. Pacifi c Institute for Research and Evaluation. 4 Ibid. immigrants. Retrieved from: www.salisbury.edu/nursing/ Retrieved March 3, 2011, from http://resources.prev. haitiancultcomp/health_care_practpg3.htm. Accessed org/documents/AlcoholViolenceGruenewald.pdf. 5 Kaiser Family Foundation. (2010). Kaiser commission April 2, 2011. on key facts: The uninsured and the difference health 10 Alameda County Public Health Department, (2008). insurance makes. Washington, DC: Kaiser Family 22 Health and Health Care for Chinese-American Life and death from unnatural causes: Health and Foundation. Elders. Department of Geriatric Medicine, John A. social inequity in Alameda County. Alameda County Burns School of Medicine, University of Hawaii. Public Health Department, Oakland, CA. 6 Ibid. Retrieved from: http://www.stanford.edu/group/ 11 ethnoger/chinese.html. . Accessed March 31, 2011. Gruenewald, P., & Remer, L. (2006). Changes in outlet densities affect violence rates. Alcoholism:

References 57 Clinical and Experimental Research, 30 (7), 1184-1193. Transportation%20Recommendations-4-28-2010.pdf. Accessed February 12, 2011. 12 Scribner, R., MacKinnon, D., & Dwyer, J. (2004). Alcohol outlet density and motor vehicle crashes in Los Angeles 5 Centers for Disease Control and Prevention. (2008). County cities. Journal of Studies on Alcohol, 55 (4), Overweight and obesity. Retrieved from: 447-453. www.cdc.gov/nccdphp/dnpa/obesity/index.htm. Accessed February 1, 2011. 13 Alameda County Public Health Department, (2008). Life and death from unnatural causes: Health and social 6 Transportation Research Board of the National inequity in Alameda County. Alameda County Public Academies. (2005). Does the built environment infl uence Health Department, Oakland, CA. physical activity? Examining the evidence. TR News, Issue 237, 31-33. Washington, DC: Transportation 14 Centers for Disease Control and Prevention, (2009). Research Board. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. 7 Centers for Disease Control and Prevention. (2001). Increasing physical activity: A report on recommendations 15 Ibid. of the task force on community preventive services. Retrieved from: http://www.cdc.gov/mmwr/preview/ 16 Lynch, M. (2003). Consequences of children’s exposure mmwrhtml/rr5018a1.htm. Accessed March 8, 2011. to community violence. Clinical Child and Family Psychology Review, 6 (4), 265-74. 8 Kahn, E. (2002). The effectiveness of interventions to increase physical activity. American Journal of 17 Bingenheimer, J., Brennan, R., & Earls, F. (2005). Preventative Medicine, 22, 87-88. Firearm violence exposure and serious violent behavior. Science, 308, 1323-1326. 9 The Trust for Public Land. (2004). No place to play: a comparative analysis of park access in seven major cities. 18 Offi ce of Justice Programs. (2002). Overview of San Francisco, CA: The Trust for Public Land. the research literature on consequences of criminal victimization. National Criminal Justice Referral Service. 10 The Trust for Public Land. (2005). The benefi ts of parks: US. Dept. of Justice. Retrieved March 7, 2011, from http:// Why America needs more city parks and open space. San www.ncjrs.gov/html/ojjdp/yv_2002_2_1/page1.html. Francisco, CA: The Trust for Public Land.

19 Prevention Institute, (2009). A public health approach to 11 Groenewegen, P., van den Berg, A., de Vries, S., & preventing violence: FAQ. UNITY. Verheij, R. (2006). Vitamin G: effects of green space on health, well-being, and social safety. BMC Public Health, 20 Ibid. 6, 149.

21 Bureau of Justice Statistics. Criminal Victimization in the 12 Frank, L., Engelke, P., & Schmid, T. (2003). Physical United States, 2003: Statistical Tables. activity and public health. In health and community design: The impact of the built environment on physical activity. Washington, DC: Island Press.

PARKS & PHYSICAL 13 Center for Quality Growth and Regional Development, ACTIVITY Georgia Institute of Technology. (2006). Healthy housing: Forging the economic and empirical foundation. Atlanta, GA: Georgia Institute of Technology. 1 Cohen, D., McKenzie, T., Sehgal, A., Williamson, S., Golinelli, D., & Lurie, N. (2007). Contribution of public 14 parks to physical activity. Am J Public Health, 97(3), Gordon-Larsen, P, Nelson, M. C., Page, P., & Popkin, 509-514. B. (2006). Inequality in the built environment underlies key health disparities in physical activity and obesity. Center for Quality Growth and Regional Development, Pediatrics, 117, 417-424. Georgia Institute of Technology. (2006). Healthy housing: Forging the economic and empirical foundation. Atlanta, GA: George Institute of Technology. CONCLUSION

2 Frumkin, H., Frank, L., & Jackson, R. (2004). Urban 1 Woolf SH, Johnson RE, Fryer GE, Rust G, Satcher D, sprawl and public health. Designing, planning, and The Health Impact of Resolving Racial Disparities: An building for healthy communities. Washington, DC: Island Analysis of US Mortality Data, American Journal of Public Press. Health, December 2004: 94 (12); 2078-2081.

3 Powell, K., Martin, L., & Chowdhury, P. (2003). Places to walk: Convenience and regular physical activity. American Journal of Public Health, 93(9),1519-1521.

4 Centers for Disease Control and Prevention. (2010). CDC recommendations for improving health through transportation policy. Retrieved from: http://www. cdc.gov/transportation/docs/FINAL%20CDC%20

58 LOUISVILLE METRO HEALTH EQUITY REPORT Appendix A: Neighborhood Area Maps

Airport Buechel-Newburg-Indian Trail

t S I 65 1 d 70 y I6 3 o l 5 Allgeier F Atkinson S Squa s re e B Gardiner ik u all H e Cir 8 E c cle Of astmoo M hel P Cham 6 r d pio 4 r a n s fo r Ro k ba Legho h I nita rds rn s B a a 6 S h B l 4 g R 5 264 26 Hu a 31 v 31 6 oo z d 1 B I P D a e l Ramp 4 B p f law a I 26 6 op o i are rd n P r 5 C r h s e s k t a l i g o D it N w I a B ia hy n rr e r n t e n 65 a n o n u ss ll s L w B e 6 e et e erna b t re P c b l d 5 e v P u u A r g No

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Map Data Sources: U.S. Census Bureau and ESRI

Appendix A 59 Butchertown-Clifton-Crescent Hill

d R er iv R 1 I 7 Moc Rd king M bi ver rd Va e i 2 Z l t R it G le a x o y R l E r r d L n e n A e H v n e r ig i 71 h d M I wo g e ocki

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Map Data Sources: U.S. Census Bureau and ESRI

60 LOUISVILLE METRO HEALTH EQUITY REPORT Downtown-Old Louisville- University

d R 1 n 3 I w y 6 o lt w 5 Fern Creek il H I B

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P o en c dle S ton Rd 1 Mile Map Data Sources: U.S. Census Bureau and ESRI

Appendix A 61 B a r re t A v Germantown e St pton Lam Floyd’s Fork V in e Rd t St ille S yv elb S n Sh helbyville a R B d w T r r B e u S ir n D E Ken t c c d tuc k h leR ky S S d a il t l v e n y t L m lb e e t r ton h r i S U R S S f k d n t t n S a c a k i a t O i sL E e o W Sw v b A n r I 64 I 64 b fe R u 5 R d d Ho ve 6 d R A 2 n I R iso n l o l e R i S E l l a i un A m at v s l t h u r r n S

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R E t 6 C r c t e d h

I o u ri e st n H v il o t o L l T t A B r

re R e y ntlin l a n ith ger Ln n v Er e H d m B O Av w S ru ld e s H S h wn y e n R a la d u d y t n y a Ln o R R D d

M y R d k u c G r Ro n t e Rd u R L n n ocust u d 1 Ln R t R s r 3 am y d 5 B a 1 d Ad L dgeR o Ri ar ry

d n R r Fairmount y D

d B 0.5 s Hw t Rd ow ckRun e Ba t a Mile n St d R

v l d

s Rd l

H e

e Pin B e ta Valle a 2 y s

T i r rl d rCr V s a t o Miles d Th ixtonLn w n Ce R d

Highlands

t e S tead Dr yn Grins G Lexington Rd Natche Pa a zLn T d rd R o R e a p ton n m H ng Dr d E p i i R ll x e t Le l R es y d Re A ee C v Alt W h e a Vi a Alley C r sta Ct Pee m h d D y b er a w e e o te k rr v k s P I A ee rin d 64 y ty G e R D s R ir Al I 6 hri B d E e ple 4 r C ax v k a C taV rcle Hill Rd e o Ci t r r M a e e lt O tt e ist r A h A A ve a ld v Ba C p R C e r o d e ds o a Av tow L n r S n fe n ic o u e u n C R R v n l e d A e e g s a v c r Mi Pe L n v and S a n A A ve n a l e o dgel y lt lv n e w A W v ood E k R a V s A P al l L n ew e d e e o s rn v l e n llis o te A R e E B R as y tta R a E a S d e r Ln rr p r e e N r s Rd Mur e i e t tAve Hill o v n geD S r A g la e Rd er H ri d il Av s ee D V C ar vd ne ruis Pl Sp r l ur a M C r t B o r m r ss b o c D D d a D la o li c n d g o n o ra a u i e n W a y y l A o o v D A t n h A v m e W o l h v v sL a ya e ic a n n o R r A e y a D e D m R eb h W r utc Driveway D 1 Mile Map Data Sources: U.S. Census Bureau and ESRI

62 LOUISVILLE METRO HEALTH EQUITY REPORT Ba rd sto wn Rd

Woodhaven Rd

S u

b t

e B

F l u

R Sunnyhill Rd d Fern Valley Rd W at MandevilleRd ch Highview-Okolona H il l R I B d 6 r Oaklawn D i Mo 5 D r lli orhaven Dr Rossmoor Dr M e ie L Tangelo D o r ow n B Minor Ln na Lipps L c Briscoe Fe n o Ln I Clay Ave ge 6 D nb 5 u r s Ou h Ln ter Loop Outer Loop P Pi S d nec r ie A roft e s pplegate Ln R Dr st L t a e ind l o l n W e Ram a a bo Way H y h y R c n w d o d w L d y R k t R d Blue e l P R s il lick o kR ns v a

c d Ma 5 B i n L s n Miles R d E r

6 be L d th y 5

I 1 er e Exit e B l nR lDr h m

u l d u I 265 ck R S B i sl R hep Man S E a i

S Par n k r Rd a B

v D l a

G y t

len a I R e 2 ose Toebb s 6 R e Ln n 5 d s

r a

t n R 1 D

e n e

v d

a w P

A Ol L e dshire Rd i r Mile

V o ve R h ve ed e Sp T ruce

k A Dr i n zA

t p n L r Cooper C n hapel R e d r ve i Leisur Ku e

u a Ln m

T M C aple or Sprin

5 N g Dr Brook Bend Way 6 I Hillcross Dr Mount d Washing R ton Rd k M r c udLn i L D A arkgrov L nt e y le Dr Dr e e l

u k l o B o Br

y a Shelbyville R W d BullittLn Shelbyville Rd n d a i R 4 Main St st W 6 y Rd ri d 2 e R le tt h C ton I li s f o A rn ul C B lo s u F n e y in Ox e x Wa B ch y M l J-Town lA P ur ey 4 db R m l Le o d 6 n y o s 2 d e o w I e r r k r rso B D L R k n P la o nP d ro n b m n k k a w e Lyn h B I y n g Cir ro 64 imberwood b n T wn P i a t k a t r e s k o s r L h N d P n ir d Linn Station R e R B Exit 17 k I 64 I 64 E L ee u I 64 w x n r ns y it T C e d 19 g P o R n n rl ick A i la b y Taylorsvi w P T pe L lle R a a d lo k n n B Po t l lueg S B w t ra e s ss Pkw W so y id D v y r r a

A eD D e r r t t t e y t i a a b Driv w r w e e way e W T t B e uc D a l H G a r k n Dr D e r r k 1 D ng r D ld Ln i e e fie w ta S d r S n i e a t s m le b t um i O D a Mile s S l Ct a t a M d e ion E S er k i p Dr e ix xM n m ro r Galle S A lect R on D il E P r e ve d Ln A k Dr Grand d w lson Six Mile Ln l R y Co Galene Dr Reh y Bartlett Rd w e Sue Helen Dr D k v y e P d r l R A n w l R el Dominion Way D k d k g n Willowwood Way e e k d a ieL P ri re l o n R k C 65 eddin e g Rd c l n 2

n n r o n ro u li r I L Rich B B R b T B u m ar o y a s d n R u b st t o o x s w hand a

r St T n c R u a d H

S Map Data Sources: U.S. Census Bureau and ESRI

Appendix A 63 2 4 y W w e H s s to U v B F e a r o s D s x M R c r a d r yf o Northeast Jefferson a f ir A t v R e d

E Marina Dr ld Wo e lf P r n en L L Bra n 2 h S nc s ta hR i te 42 Hw v y 84 d Miles

A 1 ay S Ballardsville Rd pr in ghw gd i E M B W H a x u a 1 le it34 r o s rb I 7 p o Rd h d U o y We s L u id i r C L st e m L h n po e n a rt R 1 m C R d K I 7 ley Dr d o d R i Dar t R b e ln or ll a tp e in m I L G s r n e la s e d n r W L rs i e in R a B e n F L n n l n L d a om re n Fa d H n la ss A cto lo y ry R i ke w B nc Ln r ll I H s e s 2 n o iv n 6 H ho R T b 4 R u O r a n il r l To d s k H z l I R a W e e Dr L g t r 2 r m d ay F e r a e l L 6 nh n at m L r R C n 4 O Fa R ock n r l r d R u R d vd m D b L R l d d y ry A L W n sb O en ike n ps D a d y ld H rB n R o o d e s L U l d n r H O h n N s R m b L id l u e a ge R 5 a n H y r d r r d 6 n u P D L o 2 Po A r d lo s o n d F I d Rd l ie v l s nR lds l t r L e i o R n b s C n o M 5 uL n s s o e sa n d r r s 6 p a o n p u y e N ti i 2 A W h h r e d a nR n I t W k R o u e S J a R n R y 7 y P e d e g ik 2 l k n A t k w i c o x L y E Be N S helby vill e Rd Phoenix Hill-Smoketown-Shelby Park

I 6 Exit 4 M 6 5 I6 A il E l C dam x S abel i t t 7

5 t s 6 S S S I Pleasure Ridge Park I t y t 6 a 4 5 l

6 0.5 C Fra e I nklin St v N ry A Mile Sto E Main S 5 t I 6 E M arket St y B r a a D E Jeff a W e x t rson St Log er g te is ub in r t H M d E E Li ics a l Dr Mu bert A r hamma y St R D gu r ie d Ali Bl v iv r er F a vd e ite e L D ict rp eD o l v t o w r y r e y n S t r w I D H o l l r u H E Ch D est e n nut S I te e t b nter r E G d m d s xi p o ray St dal D T i R r r r c m e D t r yR a r 5 St d r D E o y r lD B C 6 roadw a k a y e P w R ls I r c T l S e i

o d H t g st M c t l d A t S n t t e e l d nR t S b A S sh A y u H kS n ve n Ha y o Ru i o l e l t a a S l o l e s g eR Gr r S ee F n r wood Rd id C o n B S n G e L a r S Fu o D S C r D s t Jes y W k ly t s a r S mine ay c s Ln A y a

A s rde b llaC l t e hur r l e SJ n y Ma h ryma e nR L d Winstead D hD r K S t

St S or W Page A f s Ln n r a n o Ba t r r one e ol ss Av L s e D d T S n ra lzie L a to re de E k P w e wn P or e e t i r E D i O v n a v d S k St r iew L Rd A g e V l i H e

p D ter a

s r

M Cam e Johnsontown Rd Rd Street Rd p St h 3

C 5

6 I M arret Ave A Ln shby 1 od Ln rwo I 65 Mile Silve

Map Data Sources: U.S. Census Bureau and ESRI

64 LOUISVILLE METRO HEALTH EQUITY REPORT I 64 Rudd Ave Rudd Ave

Ty le lfred Rd Portland r Av t A e S I N 6 h 4

3 T M 3 9 M ar R o i 2 ntg ne S d N om h e S ip S ry S Co t p t Po t rnw in t r a g E tland ll p L S o x ytle A t r hS i t v tD t S e T T y S t 1 G le 4 illi r A r h g v 3 t an e T S 5 t N hS t 3 t 0 Parke T S 5 r Ave N 0 B 1 t 3 an h Th S k y S T 8 S t N t 4 Ly w h 2 t S 2 leSt H T N h N s 5 St S T 3 Gar h ain U N 8 fie ld Ave T t X e 3 Je N l well Ave 6 av lig 2 ierS a N I t n 2 Slev N t A No 6 in St G S v 4 ri e ffi d r t ths th St N w S A t Alfo ve 2 t r St d St e h Av S e h 2 h s S T h te T T B d 7 t N T 9 h t t a r 5 t 1 n 3 N i S 9 rd 3 T S S S P 2 2 N 4 h t St k N 3 h O N w h 3 en S wy T N t T N 1S 0 N 0 36T 2 t 3 t Dun 2 S ca S N n S N h N t W N M I T ain S h t t 7 2 T 1

S 6 Crop R Co 9 N 4 S ow lu t t a m d n b 1 St ia S t W M t t ark R S t S et St S N 3 h S St h C t olu h 3 T mb T ia h h S T S t 0 S t T 9 T 3 St h C 18 8 S r 5 2 op t St T S 2 St 1 W h N S 6 Th S

T S 2 1 N d 4 25 Rd 3 t S 2 3 N y W S S 2 P M 2 irtle S ain S S w t t 2 h S t H T S C 8 s 1 n U

1 S

ono Mile M

Russell

WMa rket St I 6 4 I 64 W Mar t ket S S 2 Con t gress t t St h i S

x T

h 3 E W T C Main S 4 ongre W Ma t ss rk N1 2 St et S Green Aly t EddySt S t 4 W Je f S t f t R Eddy St Ceda erson St r S S S a E t t h dd t I 26 y S mp t t S T h h S V 2 erm S T T ont A h 1 h ve St 0 0 o T h neA R T l St 1 ive y t r 3 S Pa T r t k 1 D t r S t 8 h S2 1 S S S 2 T S h St S1 M h S h a 8 t diso W T S n A M a 1 D ly d T T A el i S P so 6 lley t n arkT Th St e 9 Th 0 1 r t W S 9 S h M t u 1 7 h 3 amm S t 2 T ad W 1 S A S t t Ch li Bl t e v s S 5 d S S t h nut S St S C S 1 S 1 T

Th 3 h 6 d S 7

on T 2

l S N M 2 ag 4 azine Ply 2 m S St outhC S Ell 3 iottA t ve S ade E S3 squ S ir e A 1 M WBroadway ly W Broadway 2 R t ea W Broadway T dAly S h W Bro S a Th dway t 3 1 W S B roadway 1 Mile

Map Data Sources: U.S. Census Bureau and ESRI

Appendix A 65 Shively Alg onquin P Bells Ln kwy r D Oregon Ave t h C 4

c 6 i n

r 2 l n

I a A e W W i S e l l a ch v t e Millers a h F n L A Ln e k i d n r ern C L d W n n a L e R L n k n n lu d c e b R l L r v u a D d r y T A e e k v e e A g n o t R l South Central o g al e o r p tz o h i L b V Av rt r Rd K P e F u e d ra ert 4 h Louisville

v n m D W e 6 O ou rs r d r Ln 2 R r t G I Farnsley R e p D d e m r tr a D ll S C e h p e r r E d r T boe v 7 ha u O u N S cl nR A o ve u B b i e e h d A R e y l g e v Crums P er rd n Ln w l b a a A Ma nd L Cre w e C r H Li i el o v e n A ie c H Lees w We x o d E st L i h lan lo Garrs L n ln o f n D T o L ah n e n P 5 w Ln D u h Ut L f W d m r S d A y il l uf Dr Auburn Dr 1 ll li R R r i a E 3 ca s Iow 3 H e n a r t

Ct g y n e de a ee h v w n io r h v t r T L r o H a a o T l a l S n 4 D a y n C s t 6 S n a a Mart U h o T C in Ave Ol M h entra fm 7T E l u r e a T y e 9 a W t a r d w n l K i s n lk H e d N ie Roc e 2 kford L e L a r R n i r d x

Di e y B al c Wa r r Collins iargate Ave nd Clara le a r e

G k

Longfield d

D D o

Sale o r y 2N

1 Berry Evelyn B

Fe Conn Denmark t l away l Hath

e C Mile arlisle 1S w Whitney L

liff o

Po k u

C Lansing k ch c C ar i c M s r i e her z Beec u l v

a g d t

i m i P Florence s i

n l R s n f l n

f r Adai e ra e

i e 3 5 a Exit 9 l L C h

6 t M C

r 8

a 1

P 264 264 Exit8B 1 Mile

e v I 264 I 264 L South Louisville A o

u e t i t 9 e s i S Ex r e t v 4 v 26 i I h h l l A c T e f a A L f 6 St i e e l n v S d L a P C r e M ie f N A

D d D 2 a l l Sa e r n m t Bluegrass Ave S s

a o l i n c st St

k dA t

d R y S R t v d e Arling kw S Ave P 1 r Gagel Ave rn S3 e S D th r Dr s ou este n S och ru Gh R B eens Ave

r eak Blvd L s P aughl Pike D N r y n e L a d r r d w y w D R D r R eD r i n r l l n er i l l C w o i e b g il C A a r p u d w N

n i D p a y U t v D a s tr i o a R e

r h S y T t y e w T d a l u l o

t o W a t

S w V o e k N N a Wi O lder d ness r R Rd D ill Palatka ve e H Rd N A ris l d r d e rp R a R e w e en in rb t v e n a d t C h r Ge E u rd a u o i F C t a Bru d c R P e Av r R e d D Rd m a k M a ic c a S R S i d ck a sl ie in t R Ln ay t r d w R an e rive A R D e D n ed M n r n t St e A h L N o r d n w r S r o a n n R a t t o t u i y o 3 s k ld s B r o 1 n e t o n o C e L w r C Y a n h C D a l u n T Mile R r t w d d c o le p h l l k ig n rg h N e R t L d te L a f n s s A l p l h Loo o R uter T O Outer Loop d

Map Data Sources: U.S. Census Bureau and ESRI

66 LOUISVILLE METRO HEALTH EQUITY REPORT Southeast Louisville I 264 V a r ll D N e k e tt 64 o w a 2 ro R R I b b ill ic u N d H h r o l g rri A a 4 v n R s r D 6 d d D I 2 o P u B n M A l le n e e 4 R v a d v t 6 e Y A t I 2 d e D e y lb e on ix rs Ln Ln o Tayl ie Rd e r Ln u orsville Rd r L r r D V le o e n St a Em Ty w in d ay lle d lv e w Ne y e ar k l G Ave onB A ar w V lA t ve P ve r bu is T lice Ra an Ln A D rg ta re v A t s ey m e di S e inl E er Rd R an k ck a rl d r o Hi M g Eh D n c le n t D r eRd y S lo D B Ln P a y il r w ss a W lv D do r re e s an a a D c Locust Ln H y s ili n n Ln e nn k kw ev Wa rL h M A e P Tr ne it le n n F i m a r bo in y rd D i I 6 du c olds d 5 u r a I n Ga e g A D s ll G v r e l t in L n r A n D na le o L Ke r L y L i ff p L rd R i o risD e ke ro n a s u e d i e C d sh i H rr n d A h i th Pa n m B u y u lo o ve c S r N L on Dr K P D S ew n r r e D r a v b D d P rA 4 ur r or D Six MileL r lm lo 6 g df n e e ay 2 R ra n s T I B o B t t d o n x n tt L u H rre 1 B w Du y Mile y w H e ixi D Dr lou an Valley Station y W S a to

W ne

i s tr a Rd e I r ll 2 Kenda et e 6 Gr R St. Matthews 4 n d

e e D r A n id D In M n b d t r R e ia i eg n Rd m l tatio d e t S R n nc As D Valley N y H h o Ri R b e r Ln y D a o d w L e n b d n o k s ri n g y d a H n w e Ln o i Be g R g r g e B R h th s d f R d ie a d L n er A l l y d n d M L R l R m o n i M o n d r M d b ma to R a r n g ro r i Rd sbo y Ln d in wn h y g rr ro ill N d e o B u S T L R D ou Rd n H th State d u C r D Hwy 841 n b a W r S mo b s I Alic p r t a 2 ante C O a le A r e r lser 6 L it h v d v h d n e A 4 F e ve s ie lan R ru Rd n od A L w R r itwo o n d e W wo ie D d w ss v O o e lm a r Rd i r d E M R e D th ll R r L r d n e ve n E w o A L x n d it20 L so R n Blenheim R s Wh ni rt a d n n o d ip d e tp m Ta d p r K s ggart Dr le R e R e l W i eG R l t n d h e a Jo Fa re g T Shelb hn yville nL O ir Rd i A f Sa d P a msg a E x a y W ms W A S R a a en ts P v B w o a H T 4 e e r e n y n u d 6 o v L d w b v 2 i n l b l r e e n I to v a B D n e A s r R v e L d g A ff s S d li n n w c i h e y L l ip vi H d n le nd r R y te d ow L e ra s n v G he n R B inc lto A I W d A n B o R y o laRd ro n ro bo Ln w n a ills rn H a d H bu ie h fi er x o e h i B ld S D s Dr Du B R I 64 I 64 r e p o g on wn a n s L l tR t Sp L o d n p r e in g D s B D 18 r xit V E Sta H iv te Hw 1 e ia y 44 n n r ie L t n Mile taAv

y 1 w ieH ix Mile D

Map Data Sources: U.S. Census Bureau and ESRI

Appendix A 67 Appendix B: Work Group Listings

Local Work Group Emily Beauregard Family Health Centers, Inc. Sasha Belenky YMCA of Greater Louisville The local Work Group was made up Mike Bramer YMCA of Greater Louisville of key local agency and community Luther Brown Communtiy Activist organization representatives. This group Nancy Carrington Center for Neighborhoods provided critical advice and assistance Khalilah Collins Kentucky Health Justice Network in the development of the Health Equity Karen Cost Louisville Metro Board of Health Report, and was involved in developing Angelique David Louisville Urban League and refi ning report content, assistance Michael Dean California Collaborative in raw data acquisition, and in thinking Catherine Fosl Anne Braden Institute for Social Justice, Univeristy of Louisville about utilization of the report. Rus Funk Community Organizer Tiffany Gonzales Center for Health Equity Special thanks to Ray Yeager, MPH Tom Gurucharri Hispanic-Latino Coalition of Louisville for analysis on age-adjusted life Makeda Harris Louisville Metro Public Health & Wellness expectancy and mortality rates by Tina Hembree Norton Cancer Institute cause for Neighborhood Areas in Rodney Martin YMCA of Greater Louisville Louisville Metro. Carolyn Miller-Cooper Louisville Metro Human Relations Commission Regina Moore Louisville Metro Public Health & Wellness Special thanks to Catherine Fosl, Ebony O’Rea Center for Health Equity (Contractor) PhD for writing and research for the Chris Owens Louisville Metro Offi ce for Women section on the historical context. Haritha Pallum Louisville Metro Public Health & Wellness Kendria Rice-Lockett Louisville Metro Parks & Recreation Angel Rubio Center for Health Equity (Contractor) Shalonda Samuels Center for Health Equity Judy Schroeder Metro United Way Lavonne White Louisville Metro Public Health & Wellness Anthony Williams Louisville Metro Parks & Recreation Deonna Williams University of Louisville Dental School National Work Group Ray Yeager Louisville Metro Public Health & Wellness (Contractor) As a part of the Health Equity Report process a national-level Work Group was organized to provide direction Ashely Bowen National Association of County and City Health Offi cials (NACCHO) for the project. A series of conference Karen Cost Louisville Metro Board of Health calls were conducted with agency Helen Deines Race, Community and Child Welfare Initiative representatives from communities that Amber Duke Anne Braden Institute for Social Justice, Univeristy of Louisville have produced Health Equity Reports in Cate Fosl Anne Braden Institute for Social Justice, Univeristy of Louisville their communities. Through the series Sharon Mierzwa Connecticut Association of Directors of Health, Inc. of conference calls the participants Carolyn Miller-Cooper Louisville Metro Human Relations Commission discussed what these communities Neba Noyan Social Compact Inc. had learned in their own Health Equity Ebony O’Rea Center for Health Equity (Contractor) Report processes, and provided key input Haritha Pallum Louisville Metro Public Health & Wellness in the conceptualization of a framework Bob Prentice Bay Area Regional Health Inequities Initiative (BARHII) for the Louisville Health Equity Report. Michael Royster Virginia Department of Health Lisa Tobe Center for Health Equity Carolina Valencia Social Compact Inc. Ray Yeager Louisville Metro Public Health & Wellness (Contractor) Ianita Zlateva Connecticut Association of Directors of Health, Inc.

68 LOUISVILLE METRO HEALTH EQUITY REPORT Appendix B

Appendix E: Analysis of Health Information and Primary Data

Jewish Hospital Analysis of CHNA Data

Analysis of Health Status-Leading Causes of Death (A) (B) County Rate U.S. Age 10% of U.S. Less U.S. Adjusted Adjusted Adjusted If (B)>(A), then Death Rates Death Rate County Rate Death Rate "Health Need" Jefferson County Cancer 183.8 18.4 237.3 53.5 Health Need Heart Disease 211.1 21.1 241.6 30.5 Health Need Chronic Lower Respiratory Disease 43.2 4.3 65.4 22.2 Health Need Stroke/Cerebrovascular Disease 46.6 4.7 53.6 7.0 Health Need

Bullitt County Cancer 183.8 18.4 134.4 -49.4 Heart Disease 211.1 21.1 138.6 -72.5 Chronic Lower Respiratory Disease 43.2 4.3 50.4 7.2 Health Need Stroke/Cerebrovascular Disease 46.6 4.7 26.6 -20.0

Nelson County Cancer 183.8 18.4 202.1 18.3 Heart Disease 211.1 21.1 177.8 -33.3 Chronic Lower Respiratory Disease 43.2 4.3 43.8 0.6 Stroke/Cerebrovascular Disease 46.6 4.7 53.6 7.0 Health Need

Shelby County Cancer 183.8 18.4 162.2 -21.6 Heart Disease 211.1 21.1 185.8 -25.3 Chronic Lower Respiratory Disease 43.2 4.3 20.9 -22.3 Stroke/Cerebrovascular Disease 46.6 4.7 65.4 18.8 Health Need

Analysis of Health Status-Primary Health Conditions Responsible for Inpatient Hospitalization Heart Disease Mental or Emotional Diagnosis COPD Cancer Stroke

Analysis of Health Outcomes and Factors (A) (B)

30% of County Rate National National Less National If (B)>(A), then Benchmark Benchmark County Rate Benchmark "Health Need" Jefferson County Adult Smoking 14.0% 4.2% 24.0% 10.00% Health Need Adult Obesity 25.0% 7.5% 34.0% 9.00% Health Need Physical Inactivity 21.0% 6.3% 29.0% 8.00% Health Need Excessive Drinking 8.0% 2.4% 14.0% 6.00% Health Need Motor Vehicle Crash Rate 12 4 13 1 Sexually transmitted infections 84 25 568 484 Health Need Teen Birth Rate 22 7 51 29 Health Need Uninsured 11.0% 3.3% 14.00% 3.00% Primary Care Physicians 631 189 740 109 Diabetic Screen Rate 89.0% 26.7% 85.00% 4.00% Mammography screening 74.0% 22.2% 70.00% 4.00% Violent Crime Rate 73 22 646 573 Health Need Children in Poverty 13.0% 3.9% 24.00% 11.00% Health Need Children in single-parent households 20.0% 6.0% 41.00% 21.00% Health Need Limited access to Healthy Foods 0.0% 0.0% 5.00% 5.00% Health Need Jewish Hospital Analysis of CHNA Data

Analysis of Health Outcomes and Factors (continued) (A) (B)

30% of County Rate National National Less National If (B)>(A), then Benchmark Benchmark County Rate Benchmark "Health Need" Bullitt Adult Smoking 14.0% 4.2% 31.0% 17.00% Health Need Adult Obesity 25.0% 7.5% 34.0% 9.00% Health Need Physical Inactivity 21.0% 6.3% 34.0% 13.00% Health Need Excessive Drinking 8.0% 2.4% 8.0% 0.00% Motor Vehicle Crash Rate 12 4 17 5 Health Need Sexually transmitted infections 84 25 173 89 Health Need Teen Birth Rate 22 7 35 13 Health Need Uninsured 11.0% 3.3% 15.00% 4.00% Health Need Primary Care Physicians 631 189 5749 5118 Health Need Diabetic Screen Rate 89.0% 26.7% 82.00% 7.00% Mammography screening 74.0% 22.2% 68.00% 6.00% Violent Crime Rate 73 22 130 57 Health Need Children in Poverty 13.0% 3.9% 15.00% 2.00% Children in single-parent households 20.0% 6.0% 30.00% 10.00% Health Need Limited access to Healthy Foods 0.0% 0.0% 17.00% 17.00% Health Need

Nelson Adult Smoking 14.0% 4.2% 29.0% 15.00% Health Need Adult Obesity 25.0% 7.5% 30.0% 5.00% Physical Inactivity 21.0% 6.3% 29.0% 8.00% Health Need Excessive Drinking 8.0% 2.4% 19.0% 11.00% Health Need Motor Vehicle Crash Rate 12 4 24 12 Health Need Sexually transmitted infections 84 25 436 352 Health Need Teen Birth Rate 22 7 50 28 Health Need Uninsured 11.0% 3.3% 15.00% 4.00% Health Need Primary Care Physicians 631 189 2395 1764 Health Need Diabetic Screen Rate 89.0% 26.7% 82.00% 7.00% Mammography screening 74.0% 22.2% 62.00% 12.00% Violent Crime Rate 73 22 146 73 Health Need Children in Poverty 13.0% 3.9% 22.00% 9.00% Health Need Children in single-parent households 20.0% 6.0% 29.00% 9.00% Health Need Limited access to Healthy Foods 0.0% 0.0% 20.00% 20.00% Health Need

Shelby Adult Smoking 14.0% 4.2% 25.0% 11.00% Health Need Adult Obesity 25.0% 7.5% 35.0% 10.00% Health Need Physical Inactivity 21.0% 6.3% 28.0% 7.00% Health Need Excessive Drinking 8.0% 2.4% 11.0% 3.00% Health Need Motor Vehicle Crash Rate 12 4 20 8 Health Need Sexually transmitted infections 84 25 321 237 Health Need Teen Birth Rate 22 7 49 27 Health Need Uninsured 11.0% 3.3% 17.00% 6.00% Health Need Primary Care Physicians 631 189 2069 1438 Health Need Diabetic Screen Rate 89.0% 26.7% 82.00% 7.00% Mammography screening 74.0% 22.2% 71.00% 3.00% Violent Crime Rate 73 22 191 118 Health Need Children in Poverty 13.0% 3.9% 18.00% 5.00% Health Need Children in single-parent households 20.0% 6.0% 27.00% 7.00% Health Need Limited access to Healthy Foods 0.0% 0.0% 15.00% 15.00% Health Need

Issues Identified through Primary Data Access to Care Health Knowledge Addiction/Substance Abuse Stroke Obesity Respiratory Illness Communication/Health Education

Issues of Uninsured Persons, Low-Income Persons and Minority/Vulnerable Populations Heart Disease is higher for Black or African American Lack of Physical Activity in some neighborhoods Increased Chronic Diseases

Appendix F: Acknowledgements

Acknowledgements

The project Steering Committee was the convening body for this project. Many other individuals including community residents, key informants, and community-based organizations contributed to this community health needs assessment.

Project Steering Committee

Allen Montgomery, KentuckyOne Health - Senior Vice President, Community Health and Advocacy Alice Bridges, KentuckyOne Health – Vice President, Health Communities

Organizations Represented at Community Health Needs Assessment Meeting Greater Louisville Medical Society March 29, 2012

Baptist Hospital East Family Health Centers, Inc. Frazier Rehab Institute General Electric Greater Louisville Medical Society The Healing Place Jefferson Alcohol Drug Abuse Center Kentucky Office for Refugees KentuckyOne Health Kentucky and Indiana Stroke Association Louisville Metro Department of Corrections Louisville Metro Department of Public Health and Wellness Louisville Transgender Social Outreach & Support March of Dimes Metro United Way Norton Healthcare Park DuValle Family Health Clinic Parkinson Support Center Seven Counties Services University Medical Associates University of Louisville University of Louisville School of Dentistry University of Louisville Hospital Walgreens Pharmacy

Appendix G: Sources

Sources

2012.1 Nielsen Demographic Update, The Nielsen Company, April 2011 Regional Economic Conditions (RECON). 2007-2011, Federal Deposit Insurance Corporation, 8 Dec. 2011 < http://www2.fdic.gov/recon/index.asp> United States Department of Labor: Bureau of Labor Statistics. 2010. U.S. Department of Census. 8 Nov. 2011 . 2011 Poverty and Median Income Estimates – Counties, U.S. Census Bureau, Small Areas Estimate Branch, November 2012. 2010 Health Insurance Coverage Status for Counties and States: Interactive Tables. U.S. Census Bureau, Small Area Health Insurance Estimates. . Kentucky County Health Profiles: Leading Causes of Death. 2005. Kentucky Cabinet for Health and Family Services. 8 Nov. 2011 . County Health Rankings: Mobilizing Action Toward Community Health. 2011. Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. 30 Nov. 2012 . Community Health Status Indicators: CHSI 2009. U.S. Department of Health & Human Services. 8 Nov. 2011 . HealthyPeople.gov. 2011. U.S. Department of Health and Human Services. 30 Nov. 2011 . Kentucky Cabinet for Health and Family Services http://chfs.ky.gov/ FBI Report of Offenses Known to Law Enforcement.